lecture 6

Question 1

Why does inflammation occur?

Answer 1

• injurious stimuli cause a protective vascular connective tissue reaction called “inflammation”
• • dilute
• • destroy
• • isolate
• • initiate repair

Question 2

What forms of inflammation are there?

Answer 2

• acute and chronic forms

Question 3

What are the key components of inflammation?

Answer 3

• cells: endothelial cells, migratory cells such as neutrophils
• mediators: many chemicals released
• immune system: innate and acquired

Question 4

What is the chemical mediator theory?

Answer 4

• chemical substances called mediators, released from injured or activated cells coordinate the development of the inflammatory response

Question 5

What are chemical mediators?

Answer 5

• generated either from cells or from plasma proteins
• activated in response to various stimuli (inactive form or more produced)
• one mediator can stimulate the release of other mediators. Such cascades provide mechanisms for amplifying - or, in certain instances, counteracting - the initial action of a mediator
• mediators vary in their range of cellular targets
• once activated and released from the cell, most of these mediators are short-lived (don’t want to keep promoting acute response inappropriately)
• mediators constitute a self regulated system of checks and balances that regulate their actions

Question 6

Why does acute inflammation occur?

Answer 6

• prevent and limit injury, infection: protection
• interact with components of the adaptive immune system
• prepare the area of injury for healing

Question 7

What are the immediate and early responses to tissue injury?

Answer 7

1. vasodilation (leads to redness/heat)
2. vascular leakage and edema
3. leukocyte migrations (mostly PMNs = neutrophils)

Question 8

What is vasodilation?

Answer 8

Brief arteriolar vasoconstriction followed by vasodilation

• expansion of capillary bed
• increased blood flow
• accounts for warmth and redness
• opens microvascular ‘beds’
• increased intravascular pressure causes an early transudate (protein-poor filtrate of plasma) into interstitium (vascular permeability still not increased yet)

Question 9

What is vascular permeability?

Answer 9

• transudate gives way to exudate (protein-rich)

- increases interstitial osmotic pressure contributing to edema (water and ions)

Question 10

What mechanisms cause vascular permeability?

Answer 10

• many mechanisms known to cause vascular leakiness/endothelial retraction or damage
• • histamines**, bradykinins, leukotriens cause an early, brief (15-30min) immediate transient response in the form of endothelial cell contraction that widens intercellular gaps of venules
• • cytokine mediators (TNF, IL-1) induce endothelial cell junction retraction through cytoskeleton reorganisation (4-6 hrs post injury, lasting 24 hours or more)

Question 11

What might severe injuries cause in regards to vascular permeability?

Answer 11

severe injuries may cause:

• immediate direct endothelial cell damage (necrosis, detachment) making them leaky until they are repaired (immediate sustained response)
• or may cause delayed as in thermal or UV injury or some bacterial toxins (delayed prolonged leakage)

Question 12

What is increased transcytosis?

Answer 12

• certain mediators (VEGF) may cause increased transcytosis via intracellular vesicles which travel from the luminal to basement membrane surface of the endothelial cell

Question 13

What is immune cell mediated endothelial damage?

Answer 13

• marginating and endothelial cell-adherent leukocytes may pile-up and damage the endothelium through activation and release of toxic oxygen radicals and proteolytic enzymes (destroy pathogens but can destroy endothelial cells)

Question 14

Through what sequence of events do leukocytes leave the vasculature?

Answer 14

1. margination and rolling
2. adhesion and transmigration
3. chemotaxis and activation

Question 15

What are leukocytes free to do once they leave the vasculature?

Answer 15

• phagocytosis and degranulation

- collateral damage: leukocyte-induced tissue injury

Question 16

What are the kinetics of oedema and cellular infiltration?

Answer 16

• oedema first, rapid
• neutrophils rapid but later
• macrophages slower, peak later

Question 17

What is the mechanism of margination and rolling?

Answer 17

• with increased vascular permeability, fluid leaves the vessel causing leukocytes to settle-out of the central flow and “marginate” along the endothelial surface
• P-selectin and E-selectin on the endothelial cell interact with the Integrins and Sialyl-Lewis X-modified glycoproteins on the neutrophil (receptor-ligand interaction)
• P-selectins and E selectins in high numbers on the inner endothelial surface only around the site of injury (retracted in normal endothelial cells)
• once neutrophils see these receptors they begin to slow down and begin this rolling behaviour until they interact with more and more receptors and once there is a ‘threshold of triggering’
• cells change to migrate through using another type of receptor (PECAM-1/CD31): pushes the cells through the gaps between the endothelial cells
• some release of chemokines trigger change in cell behaviour response

Question 18

What is early rolling adhesion mediated by?

Answer 18

• the selectin family
• e-selectin (endothelium), p-selectin (platelets, endothelium), bind other surface molecules that are upregulated on endothelium by cytokines (TNF, IL-1) at injury sites
• p-selectin in cell in Weibel-Palade bodies but not on cell surface - stimulated to surface by histamine and thrombin

Question 19

What is adhesion?

Answer 19

• rolling comes to a stop and adhesion results
• other sets of adhesion molecules participate:
  – endothelial: ICAM-1, VCAM-1
  – Leukocyte: LFA-1, Mac-1, VLA-4
  (ICAM-1 binds LFA-1/Mac-1, VCAM-1 binds VLA-4)
• ordinarily down-regulated or in an inactive conformation, but inflammation alters this (main triggers are TNF, IL-1) - very specific receptor-ligand interaction occurring
• cells that do not have correct receptors/ligands will not bind

Question 20

What is transmigration (diapedesis)?

Answer 20

• occurs after firm adhesion within the systemic venules and pulmonary capillaries via PECAM-1 (CD31) (present on neutrophils and endothelial cells)
• must then cross basement membrane
• • collagenases
• • integrins

Question 21

How do cells know where to go?

Answer 21

Chemotaxis

• leukocytes follow chemical gradient to site of injury (chemotaxis)
• • soluble bacterial products
• • complement components (C5a)
• • cytokines (chemokine subfamily e.g. IL-8)
• • Leukotrienes
• chemotactic agents bind surface receptors inducing calcium mobilisation and assembly of cytoskeletal contractile elements

Leukocytes
- extend pseudopods with overlying surface adhesion molecules (integrins) that bind ECM during chemotaxis

When undergoing chemotaxis the neutrophil develops a front and a back - becomes polarised

Question 22

What happens to macrophages (and to some extent neutrophils) once they come in contact with chemotaxins?

Answer 22

undergo activation:

• prepare AA metabolites from phospholipids
• prepare for degranulation and release of lysosomal enzymes (oxidative burst)
• regulate leukocyte adhesion molecule affinity as needed

Question 23

What are chemical mediators?

Answer 23

Cell-derived:
Preformed:
- histamine: mast cells, basophils, platelets
- serotonin: platelets
Newly synthesised:
- prostaglandins: all leukocytes, mast cells
- leukotrienes: “,”
- platelet-activating factor: “, EC
- Reactive oxygen species: “
- Nitric oxide: macrophages, EC
- Cytokines: macrophages, lymphocytes, EC, mast cells
- Neuropeptides: leukocytes, nerve fibres

Plasma derived: 
complement: 
-C3a/5a (anaphylotoxins), 
-C3b, C5b-9 (membrane attack complex)
Factor XII (Hageman factor) activation 
- kinin system (bradykinin) 
- coagulation/fibrinolysis 
many in "pro-form" requiring activation (enzymatic cleavage)

Question 24

What are the major chemical mediator systems in inflammation?

Answer 24

Plasma proteins

i) complement
ii) kinin system
iii) clotting system
iv) fibrinolytic system (system used to get rid of blood clot/return system to normal)

Vasoactive amines

Arachidonic Acid Metabolites

Cytokines and Chemokines

Question 25

What are the major features of chemical mediators?

Answer 25

- may or may not utilise a specific cell surface receptor for activity - may also signal target cells to release other effector molecules that either amplify or inhibit initial response (regulation) - are tightly regulated - - quickly decay (AA metabolites), are inactivated enzymatically (kininase), or are scavenged (antioxidants)

Question 26

What are the plasma mediator systems initiated by coagulation factor XII?

Answer 26

Factor XII = Hageman factor - involved in blood clot mechanism - kinin cascade that ultimately produces bradykinin that is an important mediator - clotting cascade: most important factor here in terms of inflammation is thrombin - fibrinolytic system - complement cascade: C3 and C5 are the only complement proteins to have a direct influence on the inflammatory response - integration of all these pathways --> feed into one another/influence each other

Question 27

What is the clotting cascade?

Answer 27

Cascade of plasma proteases - factor XII (Hageman factor) - activated platelets converts XII to XIIa (active form) - ultimately XIIa activates thrombin which in turn converts soluble fibrinogen to insoluble fibrin clot - factor XIIa simultaneously activates the "brakes" through the fibrinolytic system to prevent continuous clot propagation - you want the clot to be in a defined region (opposing mechanism) - components role in inflammation: thrombin regulates leukocyte adhesion and fibroblast proliferation

Question 28

What is the kinin system?

Answer 28

leads to formation of bradykinin from cleavage of precursor (HMWK = high MW kininogen) - vascular permeability - arteriolar dilation - non-vascular smooth muscle contraction (e.g. bronchial smooth muscle) - causes pain - rapidly inactivated (kininases) - intimate association with clotting pathway

Question 29

What is the complement system?

Answer 29

- extremely complex - normally used to attack a pathogen - in this context the important part for the inflammatory response is C5a and C3a - recruitment and activation of white blood cells - involved in the destruction of microbes

Question 30

What are vasoactive amines?

Answer 30

Histamine: - vasodilation and venular endothelial cell contraction - junctional widening - released by mast cells - basophils - platelets in response to injury (trauma, heat, cold) - preformed in mast cell granules - connective tissue adjacent to blood vessels, also basophils and platelets

Question 31

What is the role of nitric oxide?

Answer 31

- sort-acting soluble free-radical gas with many functions - produced by endothelial cells, macrophages - causes: - - vascular smooth muscle relaxation and vasodilation - - kills microbes in activated macrophages - - counteracts platelet adhesion, aggregation, and degranulation

Question 32

What is the role of arachidonic acid metabolites (eicosanoids)?

Answer 32

- prostacyclin and thromboxane have opposing effects: vasodilation vs vasoconstriction - COS is the target of aspirin and other NSAIDs (non steroidal anti-inflammatory drug) - Leukotrienes: via lipoxygenase pathway; are chemotaxins, vasoconstrictors, cause increased vascular permeability, and bronchospasm - PAF (platelet activating factor): derived also from cell membrane, phospholipid, causes vasodilation, increased vascular permeability, increases leukocyte adhesion (integrin conformation)

Question 33

What do steroids inhibit in the arachidonic acid pathway?

Answer 33

- steroids are inhibitors of the whole downstream pathway - more potent

Question 34

What do aspirin and other NSAIDs inhibit in the AA pathway?

Answer 34

- COX-1 and COX-2 (cyclooxygenase) | - still have the ability of the other pathways

Question 35

What are cytokines?

Answer 35

- proteins that act via specific cell surface receptors, as a message to other cells modulating cell function - IL-1, TNF-alpha and -beta, IFN-gamma are especially important in inflammation - increase endothelial cell adhesion molecule expression, activation and aggregation of PMNs and many other immune roles

Question 36

What are strategies for inhibiting cytokines?

Answer 36

- reduce cytokine producing cells (e.g. with cytostatics) - inhibitory cytokines (e.g. IL-10) - inhibitors of signal transduction (e.g. cyclosporin) - regulation of gene expression (e.g. glucocorticoids) (glucocorticoids have widespread effects, often in negative ways, so important to try and find other drugs to deal with inflammation) - reduction in circulating cytokines (e.g. monoclonals, soluble receptors) - receptor blockade (e.g. antagonists or monoclonals)

Question 37

What are lysosomal components in relation to mediators of inflammation?

Answer 37

- leak from PMNs and macrophages after cell death - acid proteases (only active within lysosomes) - neutral proteases such as elastase and collagenase are destructive in ECM - counteracted by serum and ECM anti-proteases

Question 38

What are some of the systemic effects of acute inflammation?

Answer 38

Fever - one of the easily recognised cytokine-mediated (esp. IL-1, IL-6, TNF) acute-phase reactions including - - anorexia - - skeletal muscle protein degradation - - hypotension Leukocytosis - elevated white blood cell count

Question 39

What are natural mediators which suppress inflammation?

Answer 39

- ACTH, GCs - products of the HPA axis - Cytokines such as IL-10 - Lipocortin-1 (Annexin-1)