Inflammation Seminar by Dr Pratik
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Good Morning….
Presented by- Dr Pratik Pipalia, CODS, DVG
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Available @http://www.4shared.com/file/0qV66d9k/
inflammation_by_dr_pratik.html
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PPT Available @http://www.4shared.com/file/0qV66d9k/
inflammation_by_dr_pratik.html
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INTRODUCTION
HISTORY
DEFINITION
CAUSES
CARDINAL SIGNS OF INFLAMMATION
TYPES OF INFLAMMATORY REACTIONS
CONTENTS
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ACUTE INFLAMMATION
VASCULAR EVENTS
CELLULAR EVENTS
CHEMICAL MEDIATORS OF INFLAMMATION
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CHEMICAL MEDIATORSOF INFLAMMATION
VASOACTIVE AMINES ARACHIDONIC ACID
METABOLITES CYOKINES AND CHEMOKINES LYSOSOMAL CONSTITUENTS OF LEUKOCYTES OTHER MEDIATORS
PLASMA PROTEINS PLATELET ACTIVATING FACTORS NITRIC OXIDE OXYGEN DERIVED FREE RADICALS NEUROPEPTIDES
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SUMMARY OF MEDIATORS OF INFLAMMATION
INFLAMMATORY CELLS
OUTCOMES IN INFLAMMATION
EVENTS IN THE RESOLUTION OF INFLAMMATION
CHRONIC INFLAMMATION
APPLIED ASPECTS
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LYMPHATICS IN INFLAMMATION
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LYMPHATIC SYSTEM
Lymphatic system consists of a fluid called lymph, vessels called lymphatic vessels that transports the lymph, a no. of structures and organs containing lymphatic tissue, and red bone marrow, where stem cells develop into various types of blood cells, including lymphocytes
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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Drain excess interstitial fluid
Transports dietary fluids
Carries out immune responses
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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LYMPHATIC CAPPILLARIES
LYMPHATIC VESSELS
LYMPH NODES
LYMPH TRUNKS
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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LYMPH
ENDOTHELIUM OF LYMPHATIC CAPILLARY
TISSUE CELL
INTERSTITIAL FLUID ANCHORING FILAMENTS
OPENING
LYMPHATIC CAPPILLARY
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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LEFT JUGULAR TRUNK
RIGHT JUGULAR TRUNK
LEFT SUBCLAVIAN TRUNK
RIGHT SUBCLAVIAN TRUNK
THORACIC (left lymphatic)DUCT
LYMPHATIC DUCT
SUPERIOR VENECAVA
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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AGEING AND INFLAMMATION
Ageing
Inflammation
Chronic diseases
Chronic diseases .eg
Cancer
Inflammation
Ageing
Ahmad A, Banerjee S, Wang Z, Curr Aging Sci. 2009; 2(3): 174–186.
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worn-out cellular machinery spontaneous mutations accumulation of damaged nucleic
acids & proteins + generation of toxic substances
Approximately 20% of all human cancers in adults result either from chronic inflammatory state or have inflammatory etiology
Ahmad A, Banerjee S, Wang Z, Curr Aging Sci. 2009; 2(3): 174–186.
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END-RESULT
--susceptibility to oncogene activation --suppression of suppressor gene function
development and progression of cancer.
Ahmad A, Banerjee S, Wang Z, Curr Aging Sci. 2009; 2(3): 174–186.
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Non-cancer chronic diseases such as diabetes, Alzheimer's disease, Parkinson's disease, atherosclerosis, sarcopenia, and osteoporosis are also intimately connected with aging
initiated or worsened by systemic inflammationsuggests biochemical relevance of inflammation in cancer and other chronic diseases
Ageing ---- free radical-induced/mediated generation/activation of signaling molecules & transcription factors
generation of pro-inflammatory molecules
induction of a chronic inflammatory state
Ahmad A, Banerjee S, Wang Z, Curr Aging Sci. 2009; 2(3): 174–186.
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Aged residential phagocytes :macrophages & PMN’s within host
↓
inappropriate respiratory burst
↓
release of reactive nitrogen and oxygen intermediates
↓
decrease the ability to destroy pathogens
Ahmad A, Banerjee S, Wang Z, Curr Aging Sci. 2009; 2(3): 174–186.
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Aged dendritic cells (DCs)
↓
less efficient in activating T and B cells aged
↓
natural killer (NK) cells ↓ ability and efficiency
in killing tumor cells
Ahmad A, Banerjee S, Wang Z, Curr Aging Sci. 2009; 2(3): 174–186.
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↑ production of pro-inflammatory cytokines, IL-1, IL-6 and TNF-α, compared to young people
Ahmad A, Banerjee S, Wang Z, Curr Aging Sci. 2009; 2(3): 174–186.
Up-regulated COX-2 and resulting ↑ production of PGE2
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INTRODUCTION
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HISTORY
The earliest reference to inflammation in ancient medical literature is of the Smith Papyrus from around 3000 B.C. Egypt
The use of a symbol of a flame, as the determinant, shows that the ancient Egyptians, associated inflammation with heat.
Robbins And Cotran, Pathologic basics of diseases,2005, 7th ed
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HISTORY
Ancient Greeks used the term “flegmonh” to mean the inflammation, - ‘to burn’
Inflammation - Latin, ‘īnflammō’ - "ignite, set alight"
Rubin’s Pathology,2012, 6th edi
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HISTORY
CORNELIUS CELSUS
Rubor Calor Dolor Tumor
Rudolf Virchow
Functio laesa
John Hunter (surgeon in 1793)
“inflammation as a non-specific body response”
Robbins And Cotran, Pathologic basics of diseases,2005, 7th ed
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Julius Cohnheim(1889)provided first microscopic description of inflammation
Elie Metchnikoff(1880S) discovered the process of phagocytosis
Paul Ehrlich and Metchinikofftheory of immunity
Thomas Lewisdemonstrated that inflammation -
chemical mediators, most of them act locally
Robbins And Cotran, Pathologic basics of diseases,2005, 7th ed
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Inflammation is defined as the reaction of vascularized living tissue to local injury [Robbins and Contran , 7th edi. ]
Inflammation is a reaction, both systemic and local, of tissues and microcirculation to a pathogenic insult [Rubin’s Path. 6th edi.]
A localized protective response elicited by injury or destruction of tissues, which serves to destroy, dilute or wall off both injurious agent and the injured tissue [Dorland's Med Dict. 32nd edi]
DEFINITION
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According to duration:- 1 Per-acute inflammation2 Acute inflammation3 Sub-acute inflammation4 Chronic inflammation
CLASSIFICATION
University of Babylon: www.uobabylon.edu.iq/uobColeges/ad_downloads/6_17350_197.pdf
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According to the cause: - 1-Mechanical inflammationtrauma, blow, kick, or sprain 2-Physical inflammation: heat, cold, electricity, or radiation3-Chemical inflammation:alkali, acid4-Biological inflammationbacteria (it has direct effect on affected tissue and indirect effect by circulating toxin), viruses, or parasites.
classification
University of Babylon: www.uobabylon.edu.iq/uobColeges/ad_downloads/6_17350_197.pdf
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ACUTEINFLAMMATION
CHRONICINFLAMMATION
CLASSIFICATION OF INFLAMMATION
Robbins And Cotran, Pathologic basics of diseases,2005, 7th ed
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SEROUS
FIBRINOUS
CATARRHAL
HAEMORRAGIC
PURULENT
ACUTE INFLAMMATION
Reide & Werner, Color Atlas of Pathology,, 2005
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CHRONIC INFLAMMATION
DIFFUSE
SUPPURATIVE
GRANULOMATOUS
FIBRINOID
Robbins And Cotran, Pathologic basics of diseases,2005, 7th ed
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Rubbin R, Strayer D; Rubbin’s Pathology, clinicopathologic foundation of medicine,2005, 5 th ed
DIFFERENCE BETWEEN EXUDATE AND TRANSUDATE
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FEATURES EXUDATE TRANSUDATE
ORIGIN ACUTE INFLAMMATION CIRCULATORY STASIS DUE TO CARDIAC / RENAL FAILURE
CHARACTER INFLAMMATORY NON-INFLAMMATORY
MECHANISM INCREASED VASCULAR PERMEABILITY
INCREASED INTRCAPILLARY PRESSURE (filtrate of blood plasma without changes in endothelial permeability)
APPEARANCE MAY CONTAIN FIBRIN FLAKES.-TURBID : due to leukocytes-HAEMORRAHGIC : due to blood
CLEAR,TRANSPARENT- MAY BE PALE YELLOW IN COLOUR
DIFFERENCE BETWEEN EXUDATE AND TRANSUDATE
Robbins And Cotran, Pathologic basics of diseases,2005, 7th ed
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FEATURES EXUDATE TRANSUDATE
PROTEIN CONTENT HIGH(2.5-3.5g/dl) [HIGH FIBRINOGEN]
LOW(<1g/dl),[LOW FIBRINOGEN]
COAGULABILITY -SPONTANEOUS COAGULABILITY DUE TO FIBRINOGEN CONTENT, -CLOTS ON STANDING
-NO SPONTANEOUS COAGULATION
SPECIFIC GRAVITY HIGH[>1.018] LOW[<1.015]
GLUCOSE CONTENT
LOW[<60mg/dl] SAME AS IN PLASMA
Ph <7.3 >7.3
CYTOLOGY INFLAMMATORY CELLS & PARENCHYMAL CELLS
MESOTHELIAL CELLS & CELLULAR DEBRI
Harsh Mohan, Essentials of pathology ,2005,3rd ed
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FEATURES EXUDATE TRANSUDATE
DISTRIBUTION OF CELLS
LARGE IN NUMBER SCANTY IN NUMBER
TOTAL LEUKOCYTE COUNT
HIGH: POLYMORPHS (in acute) & LYMPHOCYTES (in chronic inflammation)
USUALLY BELOW 100/mm3
DISTRIBUTION OF CELLS
LARGE IN NUMBER SCANTY IN NUMBER
EXAMPLES PURULENT EXUDATE SUCH AS PUS OEDMA IN CONGESTIVE HEART FAILURE
Harsh Mohan, Essentials of pathology ,2005,3rd ed
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DIFFERENCE BETWEEN ACUTE & CHRONIC INFLAMMATION
ACUTE CHRONIC
Duration Days-weeks Months –Years
Cardinal signs Present Doubtful/ not perceptible
Vascular phenomenon Present Doubtful/ not perceptible
Exudation of plasma Present Doubtful/ not perceptible
Cellular exudate Present, PMN ->macrophages & fibroblasts (later stages)
Histiocytes, lymphocytes & plasma cells
Type of inflammation Exudative Proliferative
Repair Follows debris removed
Goes side by side along with vascular+ cellular proliferation
Dey N C, A Textbook of pathology,1985,9th edition
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CAUSES
Mechanical •Injury like trauma, presence of foreign body, ligature, dead tissue, sequestrum, etc.
Physical •Thermic ( heat & cold), electricity like electric burn, x-ray etc
Chemical •Strong acids, alkalies or poisons
Non living
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CAUSES
Bacteria Viruses &
their toxinsFungi
Animal parasitesNecrosis of
tissue
Allergy
Living
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CARDINAL SIGNS OF INFLAMMATION
TUMOURRUBORCALOR DOLOR FUNCTIO LESA
Riede & Werner, Color Atlas of Pathology , 2004
TUMOURRUBOR CALOR DOLOR FUNCTIO LAESA
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COMPONENTS OF INFLAMMATION
Robbins And Cotran, Pathologic basics of diseases,2005, 7th ed
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ACUTE INFLAMMATION
Acute inflammation is a rapid response to an injurious agent that serves to deliver mediators of host defence—leukocytes and plasma proteins—to the site of injury.
Robbins And Cotran, Pathologic basics of diseases,2005, 7th ed
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• STIMULI • VASCULAR CHANGES
• TERMINATION
• CELLULAR EVENTS
ACUTE INFLAMMATION
Robbins And Cotran, Pathologic basics of diseases,2005, 7th edition
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STIMULI
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VASCULAR CHANGES
CHANGES IN VASCULAR FLOW AND CALIBER
Robbins And Cotran, Pathologic basics of diseases,2005, 7th edition
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CHANGES IN VASCULAR FLOW AND CALIBER
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VASOCONSTRICTION
RAPID BLOOD FLOW
(VASODIALATION)
SLOWING OF THE CIRCULATION
STASIS
Rubin E, Farber J L, Essential pathology, 1990, 1st edition
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NORMAL
Robbins And Cotran, Pathologic basics of diseases,2005, 7th ed
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INFLAMED
Robbins And Cotran, Pathologic basics of diseases,2005, 7th ed
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Riede & Werner, Color Atlas of Pathology , 2004
VASOCONSTRICTION
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Riede & Werner, Color Atlas of Pathology , 2004
VASODIALATION
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Riede & Werner, Color Atlas of Pathology , 2004
SLOWING DOWN OF CIRCULATION AND INCREASED PERMEABILITY OF MICROVASCULATURE
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CHANGES IN VASCULAR PERMEABILITY
INCREASE
D
NORMAL
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NORMAL MICROCIRCULATORY CONTROL
NORMAL PERMEABILITY & STRUCTURE OF MICROCIRCULATION
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NORMAL MICROCIRCULATORY CONTROL
SYSTEMIC FACTORS
LOCAL
FACTORS
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SYSTEMIC
LOCAL
VASCULAR SMOOTH MUSCLES
AUTONOMIC NERVOUS SYSTEM→
CONDITIONS IN INDIVIDUAL TISSUES
→ METABOLIC ACTIVITY
LOW HIGHArterioles- CONTRACTED Blood Flow- DIMINISHED
Arterioles- RELAX Blood Flow- ENHANCED
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NORMAL PERMEABILITY & STRUCTURE OF MICROCIRCULATION
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OUTWARD MOVEMENT OF FLUID
INWARD MOVEMENT OF FLUID
FORCES
STARLING’S HYPOTHESIS
Rubin E, Farber J L, Essential Pathology, 1990, 1st Edition
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OSMOTIC PRESSURE OF INTERSTITIAL
FLUID
TISSUE HYDROSTATIC
PRESSURE
INTRAVASCULAR HYROSTATIC
PRESSUE
OSMOTIC PRESSURE OF
PLASMA PROTEINS
OUTWARD MOVEMENT OF
FLUID
INWARDMOVEMENT OF
FLUID
Rubin E, Farber JL, Essential Pathology, 1990, 1st Edition
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NORMAL FLUID EXCHANGE ACUTE INFLAMMATION
Harsh Mohan, Essentials Of Pathology For Dental Students,2005,3rd Edition
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MECHANISMS OF VASCULAR PERMEABILITY
FORMATION OF ENDOTHELIAL GAPS IN VENULES.
DIRECT INJURY : ENDOTHELIAL CELL NECROSIS
DELAYED PROLONGED LEAKAGE.
LEUKOCYTE-MEDIATED ENDOTHELIAL INJURY.
INCREASED TRANSCYTOSIS
LEAKAGE FROM NEW BLOOD VESSELS.
Robbins And Cotran, Pathologic Basics Of Diseases,7th ed,2005
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GAPS DUE TO ENDOTHELIAL CONTRACTION
Robbins And Cotran, Pathologic Basics Of Diseases,7th ed,2005
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DIRECT INJURY
Robbins And Cotran, Pathologic Basics Of Diseases,7th ed,2005
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LEUKOCYTE DEPENDENT INJURY
Robbins And Cotran, Pathologic Basics Of Diseases,7th ed,2005
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INCREASED TRANSCYTOSIS
Robbins And Cotran, Pathologic Basics Of Diseases,7th ed,2005
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ANGIOGENESIS
Robbins And Cotran, Pathologic Basics Of Diseases,7th ed,2005
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LEUKOCYTE ADHESION
AND
TRANSMIGRATION
CHEMOTAXIS
LEUKOCYTE ACTIVATION
PHAGOCYTOSIS
CELLULAR EVENTS
Robbins And Cotran, Pathologic Basics Of Diseases,7th ed,2005
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LEUKOCYTIC EVENTS
MARGINATION ,
ROLLING &
ADHESION
EMIGRATION &
DIAPEDESIS
CHEMOTAXIS
Robbins And Cotran, Pathologic Basics Of Diseases,7th ed,2005
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NORMAL AXIAL FLOW
Harsh Mohan, Essentials Of Pathology For Dental Students,2005,3rd Edition
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MARGINATION & PAVEMENTING
Harsh mohan, essentials of pathology for dental students,2005,3rd editionRiede & Werner, Color Atlas of Pathology , 2004 Thieme
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ADHESION
Harsh Mohan, Essentials Of Pathology For Dental Students,2005,3rd EditionRiede & Werner, Color Atlas of Pathology , 2004
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EMIGRATION AND DIAPEDESIS
Harsh Mohan, Essentials Of Pathology For Dental Students,2005,3rd EditionRiede & Werner, Color Atlas of Pathology , 2004
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LEUKOCYTIC ADHESION AND TRANSMIGRATION
ADHESION•COMPLIMENTARY ADHESION MOLECULES
TRANS-MIGRATION
•CHEMOATTRACTANTS •CYTOKINES
Kumar, Abbas, Fausto ; Robbins And Cotran, Pathologic Basics Of Diseases, 2005, 7 th Edition
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COMPLIMENTARY ADHESION MOLECULES
SELECTINS
INTEGRINS
Ig SUPERFAMILY
MUCIN like glycoproteins
Harsh Mohan, Essentials Of Pathology,2005, 3rd ed
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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CHEMOTAXIS
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CHEMO
ATTRACTANT
EXOGENOUSENDOGENOUS
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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Exogenous Agents – Bacterial Products Endogenous Agents
C5a.Leukotriene β4.Cytokines,Chemokine family (IL-
8)
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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PRODUCTION OF AA METABOLITES
LYSOSOMAL DEGRANULATION & SECRETION
SECRETION OF CYTOKINES
MODULATION OF LEUKOCYTE ADHESION
MOLECULES
LEUKOCYTIC ACTIVATION
Toll – like receptors (tlrs)
7 – transmembrane G- protein coupled
receptor (gpcrs)
Receptors for cytokines
Receptors for opsonins
Expression of surface receptors
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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LEUKOCYTIC ACTIVATION
production of cytokines
LPS
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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PHAGOCYTOSIS
Robbins And Cotran, Pathologic Basics Of Diseases, 2005, 7th Edition
Phagocytosis :
is the process of Uptake of extracellular particulate matter by cells
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PHAGOCYTOSIS
RECOGNITION &
ATTACHMENT
KILLING OR
DEGRADATI
ON
ENGULFMENT
Kumar, Abbas, Fausto ; Robbins And Cotran, Pathologic Basics Of Diseases, 2005, 7 th Edition
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PHAGOCYTOSIS
RECOGNITION AND ATTACHMENT
Opsonins - C3b, IgG, lectins
ENGULFMENT STAGE
Cytoskeletal mechanisms
Degranulation
KILLING / DEGRADATION
O2-Dependent - H2O2 HOCl
O2-Independent - lysozyme, cationic proteins, defensins, lactoferrin
NO -Dependent
Kumar, Abbas, Fausto ; Robbins And Cotran, Pathologic Basics Of Diseases, 2005, 7 th Edition
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OPSONIZATION
Harsh Mohan, Essentials Of Pathology,2005, 3rd ed
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OPSONISATION
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RECOGNITION & ATTACHMENTENGULFMENT
KILLING / DEGRADATION
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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RECEPTORS FOR OPSONINS
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
Promotes phagocytosis
Opsonization
Opsonins Antibodies, Complement Proteins , Lectins.
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ENGULFMENT STAGE
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KILLING / DEGRADATION
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
KILLING / DEGRADATION
O2-Dependent - H2O2 HOCl
O2-Independent - lysozyme, cationic proteins, defensins, lactoferrin
NO -Dependent
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KILLING / DEGRADATION
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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Other mechanisms responsible for killing bacteria:
BACTERICIDAL PERMEABILITY-INCREASING PROTEIN
Causing phospholipase activation and membrane phospholipid degradation
LYSOZYME Causing degradation of bacterial coat oligosaccharides
MAJOR BASIC PROTEIN An important eosinophil granule constituent
DEFENSINS Peptides that kill microbes by forming holes in their membranes
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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PROCESS OF PHAGOCYTOSIS
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ThankYou
…
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Good Morning…
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ACUTE INFLAMMATION
VASCULAR EVENTS
CELLULAR EVENTS
CHEMICAL MEDIATORS OF INFLAMMATION
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CHEMICAL MEDIATORSOF INFLAMMATION
VASOACTIVE AMINES ARACHIDONIC ACID
METABOLITES CYOKINES AND
CHEMOKINES LYSOSOMAL
CONSTITUENTS OF LEUKOCYTES
OTHER MEDIATORS
PLASMA PROTEINS PLATELET ACTIVATING
FACTORS NITRIC OXIDE
OXYGEN DERIVED FREE RADICALS
NEUROPEPTIDES
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SUMMARY OF MEDIATORS OF INFLAMMATION
OUTCOMES IN INFLAMMATION
EVENTS IN THE RESOLUTION OF INFLAMMATION
CHRONIC INFLAMMATION
INFLAMMATION OF ORAL TISSUES
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LEUKOCYTES & ITS CONSTITUENTS
60-70% of WBC
Cytoplasm-fine pale granules
10-12μm in diameter, nucleus has 2-5 lobes connected with - chromatin
Phagocytosis
Destruction of bacteria with lysosomes, defensins & strong oxidants
NEUTROPHIL
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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2-4% of WBC
Coarse red-orange granules
10-12μm in diameter, nucleus- usually 2 lobed
Combats in allergic reactions
Destroys certain parasitic worms
EOSINOPHIL
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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0.5-1% of WBC
10-12μm in diameter nucleus bi-lobed
Coarse cytoplasmic granules- deep blue purple in colour
Liberate heparin, histamine & serotonin
Intensify the inflammatory response
BASOPHIL
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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20-25% of WBC
Includes T-cells, B-cells & NK cells
Small: 6-9μm & Large: 10-14μm in diameter resp.
Nucleus-round or slightly intended
LYMPHOCYTE
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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Mediates immune response incl. Anti-Antib reactions
B-cells →plasma cells → ANTIBODIES
T- cells attack invading viruses, cancer cells & transplanted tissue cells
NK cells attack wide variety of infectious microbes & tumour cells
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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MONOCYTE
3-8% of WBC
12-20μm in diameter , nucleus kidney/horseshoe shaped
Cytoplasm-blue gray & has foamy appearance
Phagocytosis- after transforming into fixed /wandering macrophages
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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CHEMICAL MEDIATORS
CELL DERIVED
PLASMA
DERIVED
CHEMICAL
MEDIATORS
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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PROPERTIES OF MEDIATORS
Triggered by microbial products / host
proteins.
Specific mechanism of action
Amplify/antagonize each other
Short lived
Potentially harmful
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present in preformed stores in cells
among the 1st mediators of inflammation
mainly comprise of histamines & serotonin
Robbins and Cotran, Pathologic Basics Of Diseases,2005,7thed
Vasoactive Amines
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Principal mediator of immediate transient response
↑ vascular permeability-venular gapsRichest source - mast cells GranulesAlso found in basophils & platelets
HISTAMINE
Rubin E, Farber JL, Essential Pathology, 1990, 1st Edition
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SEROTONIN
mediator of inflammation↑ vascular permeabilitysource –platelets and enterochromaffin cells
Release stimulated when platelets aggregate after contact with collagen, plasmin, & Anti-Antib complexes
Dey N C, A Text Book Of Pathology,9thed,1985
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
PROSTAGLADINS
LEUKOTRIENES
ARACHIDONIC ACID
METABOLITES
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Arachidonic Acid
Leukotrienes
LTC4, D4, E4
Cyclooxygenase
5-Lipoxygenase
Prostaglandins
Prostacyclins
Cell Damage
Cell Membrane Phospholipids
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Rubin E and Farber JL , Essential Pathology,1st ed
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Antibody ResponseProduced by platelets, basophils, mast cells, PMN, monocytes / macrophages, & endothelial cells
low concentrations -vasodilation & ↑ venular permeability
PAF causes vasoconstriction
PLATELET ACTIVATING FACTORS(PAF)
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
Also - increased leukocyte adhesion to
endothelium, chemotaxis,
degranulation, and the oxidative
burst.
Boost synthesis of other mediators-
eicosanoids, by leukocytes and other
cells
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LYSOSOMAL CONSTITUENTS OF LEUKOCYTES
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NEUTROPHIL
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
PRIMARY (AUZUROPHILIC) GRANULES
Myeloperoxidase LysozymesDefensinsBactericidal permeability
increasing proteinsElastaseCathepsin protease3GlucoronidaseMannosidasePhospolipase
PATHOGEN AND TISSUE DESTRUCTION
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NEUTROPHIL
SECONDARY (SPECIFIC) GRANULES
Lysozymes Collagenase LactoferrinHistaminasePlasminogen activatorFMLP receptors C3b proteins
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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GRANULES
EXTRA CELLULAR SPACE
VACUOLES
specific granules
azurophil granules
more readily
by lower concentrations of agonists
require high levels of agonists to be released extracellularly
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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ACID PROTEASES degrade bacteria and debris within the phagolysosomes
NEUTRAL PROTEASES are capable of degrading various extracellular components-can attack collagen, basement membrane, fibrin, elastin, & cartilage, resulting in the tissue destruction.
NEUTRAL PROTEASES can also cleave C3 and C5 directly, releasing anaphylatoxins.
NEUTROPHIL ELASTASE has been shown to degrade virulence factors of bacteria and thus combat bacterial infections.
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
FUNCTIONS
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PROTEASES
ANTIPROTEASES
(a1-antitrypsinMacroglobulin)
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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• GENETIC DEFECIENCIES
• DEFECTS IN LEUKOCYTE FUNCTION
LEUKOCYTES
APPLIED ASPECTS
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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LEUCOCYTE ADHESION PROTEINS (LAD)
LAD-1 – Defective Biosynthesis of β 2 chainLAD -2 – absence of E- selectin Antibodies to Adhesion Molecules
GENETIC DEFICIENCIES of leukocytes
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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DEFECTS IN LEUKOCYTE FUNCTIONDISEASE DEFECT
GENETIC
Leukocyte adhesion deficiency 1
Β chain of CD11/CD18 integrins
Leukocyte adhesion deficiency 2
Fucosyl transferase – synthesis – Sialylated oligosaccharide ( receptor for selectin)
Chronic granulomatous disease
Decreased oxidative burst
X- linked NADPH oxidase ( membrane component)
Autosomal recessive NADPH oxidase (cytoplasmic component)
Myeloperoxidase deficiency Absent MPO-H₂O₂ system
Chediak- Higashi syndrome Protein involved in organelle membrane docking and fusion
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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DEFECTS IN LEUKOCYTE FUNCTION
DISEASE DEFECT
ACQUIRED
Thremal injury, diabetes, malignancy, sepsis, immunodeficiencies
Chemotaxis
Hemodialysis, Diabetes mellitus
Adhesion
Leukemia, anemia, sepsis, diabetes,
Phagocytosis and microbicidal activity
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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CYTOKINES & CHEMOKINES
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All are proteins-modulate the functions of other cell types
Mainly synthesised by immune cells.
Regulate differentiation and activation of immune cells.
Partly responsible for coordination of the inflammatory response.
Act through high affinity receptors on target cells.
Cytokines.
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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Compliment Protein Cascade
Antibody Response
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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INTERLEUKINS
Molecularly defined cytokines are called interleukins, implying that they mediate communications between leukocytes
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Name Major Cellular Source Selected Biologic Effects
IFN α,β Macrophages (IFN-), fibroblasts (IFN-)
Antiviral
IFN γ (interferon) T cells, NK cells Activates macrophages, TH1 differentiation
TNF α Macrophages, T cells Cell activation, fever, cachexia, antitumor
TNF β, LT (lymphotoxin) T cells Activates PMNs
IL-1 (interleukin-1) Macrophages Cell activation, fever
IL-2 (interleukin-2) T cells T cell growth and activation
IL-3 (interleukin-3) T cells Hematopoiesis
IL-4 (interleukin-4) T cells, mast cells B cell proliferation and switching to IgE, TH2 differentiation
Jawetz, Melnick, & Adelberg's Medical Microbiology, 24th ed
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Name Major Cellular Source Selected Biologic Effects
IL-5 (interleukin -5) T Cells Differentiation of Eosinophils, activates B cells
IL-7 (interleukin-7) Bone marrow stroma cells T cell progenitor differentiation
IL-8 (interleukin-8) Macrophages, T cells Chemotactic for neutrophils
IL-10 (interleukin-10) Macrophages, T cells Inhibits activated macrophages and dendritic cells
IL-12 (interleukin-12) Macrophages Differentiation of T cells, activation of NK cells
Jawetz, Melnick, & Adelberg's Medical Microbiology, 24th ed
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Name Major Cellular Source Selected Biologic Effects
GM-CSF (granulocyte-macrophage colony-stimulating factor)
T cells, macrophages, monocytes
Differentiation of myeloid progenitor cells
M-CSF (monocyte-macrophage colony-stimulating factor)
Macrophages, monocytes, fibroblasts
Differentiation of monocytes and macrophages
G-CSF (granulocyte colony-stimulating factor)
Fibroblasts, monocytes, macrophages
Stimulates neutrophil production in bone marrow
Jawetz, Melnick, & Adelberg's Medical Microbiology, 24th ed
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CHEMOKINES
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
Family of small proteins that act primarily as chemoattractants for specific type of leukocytes.
Stimulate leukocyte recruitment in:
inflammation
constitutively control normal migration of cells through
various tissues during organogenesis.
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At least 3 families
Relative position of Cys residue determines nomenclature e.g. CXC, CC or C.
Act through 7 Transmembrane GPCR ;which also function as co-receptors for HIV entry into immune cells.
CHEMOKINES
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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synthesized from L-arginine by enzyme NOS
Potent vasodilation by relaxing vascular smooth muscle
Produced by endothelial cells, macrophages & some neurons in the brain
Acts in a paracrine manner through induction of cyclic GMP relaxation of vascular smooth muscle
NITRIC OXIDE
H2N-CH.COOH
(CH2)3
NH
C
HN NH2
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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endogenous regulator of leukocyte recruitment-↓ inflammatory responses
reduces platelet aggregation and adhesion
Plays a role during the process of angiogenesis (antiangiogenic effect)
In vivo half-life of NO is only seconds acts on-cells in close proximity
Abnormalities in endothelial production of NO- atherosclerosis, diabetes, &hypertension
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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released extracellularly from WBC
production dependent-activation of the NADPH oxidative system.
Extracellular release -↑chemokines (e.g., IL-8), cytokines amplifies inflammatory response
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
OXYGEN-DERIVED FREE RADICALS
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Endothelial cell damage, with resultant
increased
vascular permeability
Inactivation of antiproteases, such as a,-
antitrypsin
Injury to other cell types (parenchymal cells, red
blood (cells).the copper-containing serum protein
ceruloplasmin
the iron-free fraction of serum, transferrin
the enzyme superoxide dismutase, which is
found or
can be activated in a variety of cell types
The enzyme catalase, which detoxifies H202
glutathione peroxidase, another powerful H2O2
detoxifier
OXYGEN DERIVED FREE RADICAL
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NEUROPEPTIDES
- substance P- neurokinin
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OTHER MEDIATORS
HYPOXIA INDUCED FACTOR la
URIC ACID
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Good Morning…
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Lectins
immune system by recognizing carbohydrate that are found exclusively on the pathogens
Synthesized in liver, binds to carbohydrate patterns on the bacterial cell wall and lead to activation of the complement system pathways
Sugar binding proteins (not glycoproteins)
Play role in biological recognition phenomenon
e.g.Manose binding lectin [MBL]
http://en.wikipedia.org/wiki/Lectin
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Commercially available mediators
Histamine
Nitric oxide
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PGE2 Misoprostole
PGI2 iloprost, cisaprost
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Recombinant –human Erythropoietin• Anaemia of chronic
renal
Recombinant – human M-CSF• Acceleration of
myeloid recovery in patients with Lymphoma
Interferon -α• Chronic Myeloid
Leukaemia• Chronic Hepatitis C
International Journal of Pathology; 2004; 2(1):47-58
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Thrombopoietin• thrombocytope
nia due to myelosuppressive therapy
Recombinant Interleukin –11• severe
thrombocytopenia due to myelosuppresive therapy
IL- 3• Chemotherapy
induced myelosuppresion
International Journal of Pathology; 2004; 2(1):47-58
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SUMMARY OF MEDIATORS OF INFLAMMATION
OUTCOMES IN INFLAMMATION
EVENTS IN THE RESOLUTION OF INFLAMMATION
CHRONIC INFLAMMATION
INFLAMMATION OF ORAL TISSUES
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COMPLIMENT
CLOTTING
KININ
Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
COMPLEMENT ACTIVATION
begins with the formation of Ag-Ab complex
is initiated by cell-surface constituents that are foreign to the host
– Ab-independent
is activated by binding of MBL to mannose residues on glycoproteins or carbohydrates on the surface of microorganisms
– Ab-independent
CLASSICAL PATHWAY
ALTERNATIVE PATHWAY
LECTIN PATHWAY
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
COMPLEMENT ACTIVATION
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COMPLEMENT ACTIVATION
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
COMPLEMENT ACTIVATION
CLEAVAGE OF C3
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
COMPLEMENT ACTIVATION
MEMBRANE ATTACK COMPLEX
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
COMPLEMENT ACTIVATION
MEMBRANE ATTACK COMPLEX
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RESULTS OF COMPLEMENT ACTIVATION
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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Factor XII Factor XIIa
Prekallikrein Kallikrein
Plasminogen Plasmin
Fibrin
Tissue plasminogen activator
HMWK BRADYKININ
Fibrin degradatio
n products
KININ & FIRINOLYTIC SYSTEM
Burkets oral medicine,10th ed,2003
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CLOTTING SYSTEM
EXTRINSIC PATHWAY INTRINSIC PATHWAY
Tortora GJ, Derickson BH, Principles of anatomy and physiology,12th ed, Vol 2,2009
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
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MOST LIKELY MEDIATORS OF INFLAMMATION
TUMOURRUBORCALOR DOLOR FUNCTIO LEASA
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MOST LIKELY MEDIATORS OF INFLAMMATION
VASODIALATION
• PROSTAGLANDINS
INCREASED VASCULAR PERMEABILITY
• VASOACTIVE AMINES• C3a & C5a (through liberating amines)• BRADYKININ• LEUKOTRIENE C4,D4,E4,PAF
CHEMOKINES
• C5a• LEUKOTRIENE B4• OTHER CHEMOTACTIC LIPIDS• BACTERIAL PRODUCTS
Rubin E and Farber JL , Essential Pathology,1st ed
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FEVER
• INF-1, TNF• PROSTAGLANDINS
PAIN
• PROSTAGLANDINS• BRADYKININ
TISSUE DAMAGE
• NEUTROPHIL & MACROPHAGE LYSOSOMAL ENZYME• OXYGEN METABOLITES
Rubin E and Farber JL , Essential Pathology,1st ed
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Robbins And Cotran, Pathologic Basics Of Diseases,2005,7thed
OUTCOMES OF INFLAMMATION
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MORPHOLOGIC PATTERNS OF ACUTE INFLAMMATION
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ACCORDING TO THE TYPE OF EXUDATE
Serous Inflammation
Catarrhal inflammation
Fibrinous inflammation
Suppurative inflammation
Hemorrhagic inflammation
Allergic inflammation
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necrotizing inflammation
lymphocytic inflammation
fetal inflammation
Riede & Werner, Color Atlas of Pathology,1st ed,2001
SPECIAL FORMS OF ACUTE INFLAMMATION
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SEROUS INFLAMMATION
DEFINITION: Acute inflammation with exudate of fibrin-free serum.i.e. skin blister, Rhumatoid artheritis
Riede & Werner, Color Atlas of Pathology
CATARRHAL INFLAMMATION
DEFINITION: a form affecting mainly a mucous surface, marked by a copious discharge of mucus and epithelial debris. (in mucous membrane of GIT or respiratory tract).
FIBRINOUS INFLAMMATION
DEFINITION: Acute inflammation with exudation of fibrinogen-containing serum that polymerizes to fibrin outside the blood vessels.
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SUPPURATIVE INFLAMMATION
DEFINITION: Inflammation with exudate consisting primarily of neutrophils and cellular debris.
Riede & Werner, Color Atlas of Pathology
ABSCESS[ localised] PHLEGMON[ diffuse]
DEFINITION: Abscess are localized collection of purulent inflammatory tissue caused by suppuration buried in a tissue, organ or confined space
DEFINITION : It is characterized by the diffuse spread of the exudate through tissue spaces caused by virulent bacteria like streptococci without either localization or marked pus formation
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DEFINITION: Acute inflammation involving microvascular injury with massive microvascular bleeding, producing an exudate with a high erythrocyte content
HEMORRHAGIC INFLAMMATION
ALLERGIC INFLAMMATION
DEFINITION: This is an inflammation of the mucous membrane caused by powerful necrotizing toxin which produce coagulation necrosis and cause pseudomembrane formation.
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NECROTIZING INFLAMMATION
DEFINITION: Acute inflammation in which tissue necrosis predominates.
Ulcerous necrotizing. Diffuse necrotizing. Gangrenous
TYPES
Riede & Werner, Color Atlas of Pathology
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DEFINITION: Acute inflammation with focal necrosis extending into the submucosa or deeper and covered with fibrinous exudate. eg. ANUG, peptic ulcer
ULCEROUS NECROTIZING INFLAMMATION
Riede & Werner, Color Atlas of Pathology
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DIFFUSE NECROTIZING INFLAMMATION
DEFINITION: Acute inflammation with rapidly spreading necrosis & an ineffective or absent leukocyte reaction. eg. Necrotizing fascitis
Riede & Werner, Color Atlas of Pathology
GANGRENOUS INFLAMMATION
DEFINITION: Putrid disintegration of necrotizing inflammation due to infestation with anaerobic putrefactive bacteria.
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CHRONIC INFLAMMATION
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DEFINITION : chronic inflammation is inflammation of prolonged duration (weeks or months) in which active inflammation, tissue destruction, and attempts at repair are proceeding simultaneously.
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Chronic nonsuppurative inflammation;
— Chronic suppurative inflammation;
— Granulomatous inflammation
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CAUSES
Persistent infections
Prolonged exposure to potentially toxic agents
Autoimmunity
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MORPHOLOGIC FEATURES
Mononuclear Cell Infiltration
Macrophages, Lymphocytes & Plasma Cells .
Tissue Destruction
Persistent stimuli or Inflammatory Cells.
Healing By Connective Tissue Replacement
Angiogenesis & Fibrosis.
Rubin E and Farber JL , Essential Pathology,1st ed
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CHRONIC INFLAMMATORY CELLS
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LYMPHOCYTE
EOSINOPHILS
TISSUE MACROPHAGESMAST CELLS
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ORIGIN
MONOCYTES & MACROPHAGES
HALF-LIFE
STRUCTURE
CONTENTS
FUNCTION
TYPES
MACROPHAGES
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PROPERTIES MONOCYTES MACROPHAGES
Site Blood Tissues
Size Small Large
Half-Life 1 day Months to years
Characteristic of
Acute inflammation
Chronic inflammation
Secretory granules
Less in quantity More in quantity
Rubin E and Farber JL , Essential Pathology,1st ed
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TYPES
Kupffer cell (liver)
Microglia (CNS)
Histiocytes (spleen)
Alveolar macs (lung)
Harsh Mohan, Essentials Of Pathology,2005, 3rd ed
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ROLES OF ACTIVATED MACROPHAGES
Rubin E and Farber JL , Essential Pathology,1st ed
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OTHER CELLS IN CHRONIC INFLAMMATION
MAST CELLS
EOSINOPHILS
LYMPHOCYTES
Rubin E and Farber JL , Essential Pathology,1st ed
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Chronic Nonsuppurative Inflammation
DEFINITION: Chronic inflammation without suppurativetissue liquefaction.
Riede & Werner, Color Atlas of Pathology
Chronic Suppurative Inflammation
DEFINITION: This may occur as a chronic mucopurulent inflammation or a chronic granulomatous inflammation(a special form of suppurative inflammation).
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GRANULATING INFLAMMATIONS
DEFINITION: Chronic inflammations characterized by formation of new capillary-rich, absorptive mesenchyma (granulation tissue).
ZONES : Resorption zone Granulation zone Mature connective tissue zone
Riede & Werner, Color Atlas of Pathology
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Riede & Werner, Color Atlas of Pathology
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MORPHOLOGIC VARIANTS OF GRANULATING INFLAMMATIONS
— Chronic abscess;— Chronic fistula;— Chronic ulcer.
Riede & Werner, Color Atlas of Pathology
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CHRONIC PERIAPICAL ABSCESS
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CHRONIC FISTULA
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CHRONIC ORAL ULCER
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GRANULOMATOUS INFLAMMATION
Granulomatous inflammation is a distinctive pattern of chronic inflammatory reaction characterized by focal accumulations of activated macrophages, which often develop an epithelial-like (epithelioid) appearance.
Riede & Werner, Color Atlas of Pathology
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A granuloma is a focus of chronic inflammation consisting of a microscopic aggregation of macrophages that are transformed into epithelium-like cells surrounded by a collar of mononuclear, leukocytes, principally lymphocytes and occasionally plasma cells.
Riede & Werner, Color Atlas of Pathology
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Riede & Werner, Color Atlas of Pathology
TUBERCULOUS GRANULOMA
PSEUDOTUBERCULOUS GRANULOMA
SARCOID GRANULOMAS
RHEUMATIC GRANULOMA
RHEUMATOID GRANULOMA
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DEFINITION: Large circumscribed granulomas consistingof epithelioid cells with central caseous necrosis and an outer layer of lymphocytic cells.(referred to as a TUBERCLE )
TUBERCULOUS GRANULOMA
Eg: Tuberculosis Leprosy Syphilis
Riede & Werner, Color Atlas of Pathology
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TUBERCULOUS GRANULOMA
Riede & Werner, Color Atlas of Pathology
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PSEUDOTUBERCULOUS GRANULOMA
DEFINITION: Often ill-defined granulomas consisting of macrophages and epithelioid cells with central necrosis with granulocytes.
(Reticocytically absessing granuloma)
eg: Histoplasmosis Cryptococcosis Typhoid fever
Riede & Werner, Color Atlas of Pathology
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PSEUDOTUBERCULOUS GRANULOMA
Riede & Werner, Color Atlas of Pathology
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DEFINITION: Small granulomas of epithelioid cells (noncaseating epithelioid granulomas) without central necrosis (caseation) and with an outer layer of collagen fibers.
SARCOID GRANULOMAS
Riede & Werner, Color Atlas of Pathology
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DEFINITION: Histiocytic granuloma around a core of fibrinoid collagen necrosis, occurring primarily in the myocardium and only with rheumatic fever.
RHEUMATIC GRANULOMA (Aschoff’s lesion)
Riede & Werner, Color Atlas of Pathology
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DEFINITION: Histiocytic granuloma around a core of fibrinoid collagen necrosis, often occurring at multiple locations in the subcutaneous tissue and in articular nodules in rheumatoid arthritis
RHEUMATOID GRANULOMA
Riede & Werner, Color Atlas of Pathology
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DEFINITION : Histiocytic granuloma surrounding material that the body can break down only with difficulty or not at all and that has lodged in or been released into tissue.
FOREIGN-BODY GRANULOMA
Riede & Werner, Color Atlas of Pathology
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EFFECTS OF INFLAMMATION
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LOCAL EFFECTS
SYSTEMIC EFFECTS
INFLAMMATION OF ORAL TISSUES
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LOCAL EFFECTS
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EXUDATE :
LOCAL EFFECTS
The escape of fluid, proteins and blood cells from the
vascular system into interstitial tissue or body
cavities. Plasma filtrate without changes in vascular permeability
Excess of fluid in the interstitial or serous cavitiesEDEMA :
TRANSUDATE :
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SYSTEMIC EFFECTS IN INFLAMMATION
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The systemic changes associated with inflammation, especially in patients who have infections, are collectively called the acute phase response, or the systemic inflammatory response syndrome (SIRS)."
SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS)
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FEVER
PYROGENS PG synthesis (PGE) in Hypothalamus
Neurotransmitter cAMP
Reset the TEMPERATURE
HIGH-POINT
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PYROGENS
EXOGENOUS PYROGENS (Bacterial LPS)
ENDOGENOUS PYROGENS
(Leukocytes→cytokines
→ IL-1, TNF)
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ACUTE PHASE PROTEINS
C-reactive protein (CRP) Fibrinogen Serum amyloid A protein
(SAA)
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C-reactive protein (CRP) Fibrinogen Serum amyloid A protein
(SAA)
HEPATOCYTES Up regulated by CYTOKINES
IL-6
IL-1/ TNF
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CRP & Fibrinogen
+bacterial
CELL WALL
OPSONINS &
fix compliment
FIBRINOGEN
RBC
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LEUKOCYTOSIS
15,000 OR 20,000 Cells/pl,
LEUKEMOID REACTON
Prolonged infections
CSF
Proliferation of precursors in the bone marrow
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Chills
Rigors
Malaise
Anorexia
Decreased sweating
Increased pulse and blood
pressure
OTHER MANIFESTATIONS OF ‘SIRS / APR’
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INFLAMMATION OF ORAL TISSUES
SOFT TISSUES
HARD TISSUES
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ORAL SOFT TISSUE inflammationS
PULPITIS
PERIODONTITIS
RECURRENT APTHOUS ULCERS
ORAL LICHEN PLANUS
ORAL SUBMUCOUS FIBROSIS
ORAL CANCER
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ORAL HARD TISSUE inflammationS
ALVEOLITIS
OSTEITIS
OSTEOMYELITIS
ARTHRITIS
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MISCELLANEOUS inflammation
FOLLICULITIS
DERMATITIS
RHINITIS
SINUSITIS. . . .
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PULPAL & PERIAPICAL INFLAMMATION
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PULPAL INFLAMMATION
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PULPAL INFLAMMATION
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PULPAL INFLAMMATION
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PULPAL & PERIAPICAL INFLAMMATION
Focal
Pulpitis
Acute Chronic
Apical Periodontitis
Radicular cyst
Osteomyelitis
Diffuse
PeriostitisAbscess
Cellulitis
Acute
Acute
Chronic
Chronic
Periapical
granuloma
Periapical abscess
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PERIODONTAL INFLAMMATION
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Infectious Disease – AA , P. Gingivalis , etc
Begins As Gingivitis
Bacterial Plaque – Mediators
MMP’s – collagenase , proteoglycans , etc
PDL Destruction – Immune Response ( Hypersensitivity)
PERIODONTAL INFLAMMATION
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PERIODONTAL INFLAMMATION
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RECURRENT APTHOUS ULCERS
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RECURRENT APTHOUS ULCERS
Minor
Major
Herpetiform
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RECURRENT APTHOUS ULCERS
Genetic predisposition - genotypes of IL-1B; IL-6,
Positive family history
cell-mediated immune response mechanism, and
involves generation of T-cells and TNF α
Elevated levels of interleukin-2 (IL-2) and lower levels
of IL-10 have been found.
Natural killer cells activated by IL-2 play a role in the
process of this disease
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ORAL LICHEN PLANUS
Oral lichen planus (OLP) is a common chronic immunologic inflammatory mucocutaneous disorder that varies in appearance from keratotic (reticular or plaquelike) to erythematous and ulcerative.
Burket’s Oral Medicine Diagnosis and treatment, 10th ed
Reticular Plaque Atrophic Bullous Erosive Ulcerative
TYPES
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ORAL LICHEN PLANUS
Reticular lichen planus Papular lichen planus
Atrophic lichen planus
Scully C, Carrozzo M. British Journal of Oral and Maxillofacial Surgery 46 (2008) 15–21
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ORAL LICHEN PLANUS
Erosive lichen planus Bullous lichen planus
Gingival lichen planusScully C, Carrozzo M. British Journal of Oral and Maxillofacial Surgery 46 (2008) 15–21
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ORAL LICHEN PLANUS
Common chronic inflammatory disorder affecting stratified squamous epithelia.
It is genetically induced
Genetic polymorphism of cytokines - govern whether lesions develop in the mouth alone (interferon-gamma (IFN-) associated) or in the mouth & skin (tumour necrosis factor-alpha (TNF-) associated)
Scully C, Carrozzo M. British Journal of Oral and Maxillofacial Surgery 46 (2008) 15–21
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ORAL LICHEN PLANUS
Increased production of TH1 cytokines is a key and early event in LP
T-cell-mediated autoimmune disease principally CD4+ and CD8+ lymphocytes
Gradual accumulation of CD8+ T cells with disease progression.
proportion of CD8+ cells -↑ in the superficial lamina propria.
Auto- cytotoxic CD8+ T cells trigger apoptosis of oral epithelial cells.
Porter SR, Kirby A,Olsen I, Barrett W.OOOOE 1997;83:358-66
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ANTIGENIC STIMULATION(exogenous/endogenous) *
LANGERHANS CELLS AND FACTOR XIII A DENDROCYTES INCREASE
(associated with antigenic challenge)
ENDOTHELIUM UPREGULATES ADHESION MOLECULES (E.G., ICAM AND ELAM) (induced by resident macrophages,
langerhans cells, and dendrocytes)
LYMPHOCYTES (T CELLS) RECRUITED TO AND RETAINED IN SUBMUCOSA
(Through receptors to endothelial adhesion molecules)
Regezi, Scuibba, Jordan. Oral Pathology .clinicopathologic correlation 5th ed,2009
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Basal keratinocytes neoexpress ICAM and lymphocytes attach (Through lymphocyte receptors to ICAM)
Basal keratinocytes undergo apoptosis (Mediated by lymphocyte-derived cytokines)
Hyperkeratosis (Reduced keratinocyte desquamation due to enhanced membrane adhesion)
Regezi, Scuibba, Jordan. Oral Pathology .clinicopathologic correlation 5th ed,2009
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ORAL SUBMUCOUS FIBROSIS
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ORAL SUBMUCOUS FIBROSIS
Oral submucous fibrosis (OSF) is a slowly progressive chronic fibrotic disease of the oral cavity and oropharynx, characterized by fibroelastic change and inflammation of the mucosa, leading to a progressive inability to open the mouth, swallow,or speak.
Burket’s Oral Medicine Diagnosis and treatment, 10th ed
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ORAL SUBMUCOUS FIBROSIS
ORAL MUCOSABETEL QUID
HABITCONSTANT IRRITATION
ACTIVATED T-CELL & MACROPHAGES
↑ IL-6, TNF, IF-α, TGF-β
CHRONIC INFLAMMATI
ON
Duration & frequency of the
habit
↑ susceptibility due to Fe+ & Vit B12
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Arecoline
↓ the MMP-2 secretion (gelatinolytic) ↑ TIMP-1 levels
increased deposition of collagen in the extracellular matrix
Chang YC et al 2004
Polymorphisms of the genes coding for TNF-α has been reported as a significant risk factor for OSF
↑ levels of fibrogenic cytokines : TGF-β, platelet derived growth factor (PDGF) & basic fibroblast growth factor (bFGF) in OSF tissues .
Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya SOral Oncology 2006:42;561– 568
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collagen-related genes CoL1A2, COL3A1,CoL6A1, COL6A3 and COL7A1
(altered- ingredients in the quid)
definite TGF-β targets
Induced in fibroblasts at early stagesof the disease.
may contribute to increasedcollagen levels in OSF
Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya SOral Oncology 2006:42;561– 568
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Expression of cyclooxygenase enzymes( COX-2) & inflammatory mediators esp prostaglandins
Increased in moderate fibrosis
disappeared in advanced fibrosis.
Finding compatible with - histology of the disease lack of inflammation in the advanced disease.
Biopsies from buccal mucosa of OSF cases and from controls stained for COX-2 by immunohistochemistry:
Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya SOral Oncology 2006:42;561– 568
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Why do we prescribe corticosteroids????
OSF shows a gross imbalance in ECM remodeling
Fibroblasts from OSF patients and controls were incubated with collagen beads: proportion of phagocytic cells 35% and 75% respectively.
After incubation with fibronectin coated beads, normal fibroblasts exhibited 70% internalization OSF fibroblast revealed 22% internalization.
Tsai CC, Ma RH, Shieh TY in 1999
Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya SOral Oncology 2006:42;561– 568
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Increased levels of immune complexes and raised serum levels of IgG, IgA and IgM
Tilakaratne WM et al. Oral Oncology 2006:42;561– 568
There was a dose-dependent enhancement of phagocytic cells when the cultures were treated with corticosteroids.
reduction of phagocytic cells -strongly related to the levels of arecoline in fibroblast culture
Shieh DH, Chiang LC, Lee CH, Yang YH, Shieh TY in 2004
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IMMUNE-MEDIATED SUB-EPITHELIAL BLISTERING DISEASES (IMSEBD)
PEMPHIGUS VULGARIS
Circulating Antibodies Directed Against Desmoglein 3 &
HLA class II alleles
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Pemphigoid is a heterogeneous group of putative, autoimmune, chronic inflammatory subepithelial vesiculobullous disorders affecting skin (bullous pemphigoid), mucous membranes of the oropharynx (mucous membrane pemphigoid), and eyes (ocular cicatricial pemphigoid).
MUCOUS MEMBRANE PEMPHIGOID
(MMP)
Suresh L, Kumar V, OOOOE 2007;104:359-62)
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autoantibodies—tissue bound or in circulation—
against heterogeneous molecular targets in the epithelial
basement membrane zone (BMZ)
Direct IF -- IgG, IgA, &/or complement C3 deposition in a linear band at the BMZ
The synthesis of IgG4 is dependent upon secretion of interleukins (IL-4, IL-8, and IL-10) triggered by lymphocytes in response to a chronic or repeated antigenic exposure.
Suresh L, Kumar V, OOOOE 2007;104:359-62)
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Hematoxylin-eosin, original magnification x 40. Direct immunofluorescencewith salt split, revealing monoclonal IgG4 deposits, under fluorescent microscope, on the epithelial side of separation in A1 A2 Suresh L, Kumar V, OOOOE 2007;104:359-62)
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Hematoxylin-eosin, original magnification x 40. Direct immunofluorescence , with salt split, revealing monoclonal IgG4 deposits, under fluorescent microscope, on the epithelial side of separation in B1 B2
Suresh L, Kumar V, OOOOE 2007;104:359-62)
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ERYTHEMA MULTIFORME
It is an acute muco-cutaneous hypersensitivity reaction
characterized by a skin. SJS is usually initiated by drugs,
and the tissue damage is mediated by soluble factors .
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Erythema Multiforme (EM) is an acute mucocutaneous hypersensitivity reaction characterised by skin eruption, with or without oral or other mucous membrane lesions
CLASSIFICATION
Mild or minor
EM
More severe or major form- Stevens-Johnson syndrome
Most severe form/ Toxic epidermal necrolysis (TEN)
or Lyell’s Syndrome
Farthing P, Bagan JV, Scully C. Oral Diseases 2005:11;261-267
DCNA, Oral Soft tissue lesions.Jan 2005: 49(1);67-76
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ETIOLOGY
70%-80% : HSVOthers includeInfectious agents : Hepatitis viruses(A,B,C), EB virus, Mycoplasma pneumoniae, haemolytic streptococci, rickettsia, coccidiodomycosis, histoplasmosis, TrichomonasImmune conditions : Hepatitis B immunisation, IBD,SLEFood additives or : Benzoates, nitrobenzene, perfumes, terpenesChemicals Drugs : Sulphonamides, Cephalosporins, Aminopenicillins, Oxicam NSAIDs, Anticonvulsants, even corticosteriodsGenetic : HLA-B15, HLA-B35, HLA-A33, HLA-DR53, HLA-DQBI*0301 (recurrent) HLA-DQBI*0402 (rare allele associated with extensive mucosal invovement)
DCNA, Oral Soft tissue lesions. Jan 2005: 49(1);67-76Farthing P, Bagan JV, Scully C. Oral Diseases 2005:11;261-267
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IFN-γ tissue damage (Kokuba et al,1999)
expression correlates with HSV-protein expression
Farthing P, Bagan JV, Scully C. Oral Diseases 2005:11;261-267
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Drug induced lesions
TNF-α-- present in keratinocytes ; --also produced by macrophages and monocytes --mediate keratinocyte apoptosis
The mechanisms of tissue damage in EM
Virally induced EM----> IFN-γ
Drug induces EM ----> TNF-α
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HISTOPATHOLOGY OF EM MINOR.
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Other inflammatory conditions
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RECURRENT APTHOUS ULCERS
Minor
Major
Herpetiform
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RECURRENT APTHOUS ULCERS
cell-mediated immune response mechanism, and
involves generation of T-cells and TNF α
Elevated levels of interleukin-2 (IL-2) and lower levels
of IL-10 have been found.
Natural killer cells activated by IL-2 play a role in the
process of this disease
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ORAL LICHEN PLANUS
Oral lichen planus (OLP) is a common chronic immunologic inflammatory mucocutaneous disorder that varies in appearance from keratotic (reticular or plaquelike) to erythematous and ulcerative.
Burket’s Oral Medicine Diagnosis and treatment, 10th ed
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ORAL LICHEN PLANUS
Common chronic inflammatory disorder affecting stratified squamous epithelia.
It is genetically induced
Genetic polymorphism of cytokines – interferon-gamma (IFN-) associated or
tumour necrosis factor-alpha (TNF-) associated
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ORAL LICHEN PLANUS
Increased production of TH1 cytokines is a key and early event in LP
T-cell-mediated autoimmune disease principally CD4+ and CD8+ lymphocytes
Gradual accumulation of CD8+ T cells with disease progression.
proportion of CD8+ cells -↑ in the superficial lamina propria.
Auto- cytotoxic CD8+ T cells trigger apoptosis of oral epithelial cells. (epithelial-mesenchymal junction)
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ANTIGENIC STIMULATION(exogenous/endogenous) *
LANGERHANS CELLS AND DENDROCYTES INCREASE(associated with antigenic challenge)
ENDOTHELIUM UPREGULATES ADHESION MOLECULES (E.G., ICAM ) (induced by resident macrophages, langerhans cells,
and dendrocytes)
LYMPHOCYTES (T CELLS) RECRUITED TO AND RETAINED IN SUBMUCOSA
(Through receptors to endothelial adhesion molecules)
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Basal keratinocytes neoexpress ICAM and lymphocytes attach (Through lymphocyte receptors to ICAM)
Basal keratinocytes undergo apoptosis (Mediated by lymphocyte-derived cytokines)
Hyperkeratosis (Reduced keratinocyte desquamation due to enhanced membrane adhesion)
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ORAL SUBMUCOUS FIBROSIS
Oral submucous fibrosis (OSF) is a slowly progressive chronic fibrotic disease of the oral cavity and oropharynx, characterized by fibroelastic change and inflammation of the mucosa, leading to a progressive inability to open the mouth, swallow,or speak.
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ORAL SUBMUCOUS FIBROSIS
ORAL MUCOSABETEL QUID
HABITCONSTANT IRRITATION
ACTIVATED T-CELL & MACROPHAGES
↑ IL-6, TNF, IF-γ, TGF-β
CHRONIC INFLAMMATI
ON
Duration & frequency of the
habit
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Arecoline
↓ the MMP-2 secretion (gelatinolytic)
increased deposition of collagen in the extracellular matrix
↑ levels of fibrogenic cytokines : TGF-β, platelet derived growth factor (PDGF) & basic fibroblast growth factor (bFGF) in OSF tissues .
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IMMUNE-MEDIATED SUB-EPITHELIAL BLISTERING DISEASES (IMSEBD)
PEMPHIGUS VULGARIS
Circulating Antibodies Directed Against Desmoglein 3
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Pemphigoid is a heterogeneous group of autoimmune, chronic inflammatory subepithelial vesiculobullous disorders affecting skin (bullous pemphigoid), mucous membranes of the oropharynx (mucous membrane pemphigoid), and eyes (ocular cicatricial pemphigoid).
MUCOUS MEMBRANE PEMPHIGOID
(MMP)
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Erythema Multiforme (EM) is an acute mucocutaneous hypersensitivity reaction characterised by skin eruption, with or without oral or other mucous membrane lesions
CLASSIFICATION
Mild or minor
EM
More severe or major form- Stevens-Johnson syndrome
Most severe form/ Toxic epidermal necrolysis (TEN)
or Lyell’s Syndrome
ERYTHEMA MULTIFORME
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ETIOLOGY
70%-80% : HSVOthers includeInfectious agents : Hepatitis viruses(A,B,C), EB virus, Mycoplasma pneumoniae, haemolytic streptococci, rickettsia, coccidiodomycosis, histoplasmosis, TrichomonasImmune conditions : Hepatitis B immunisation, IBD,SLEFood additives or : Benzoates, nitrobenzene, perfumes, terpenesChemicals Drugs : Sulphonamides, Cephalosporins, Aminopenicillins, Oxicam NSAIDs, Anticonvulsants, even corticosteriodsGenetic : HLA-B15, HLA-B35, HLA-A33, HLA-DR53, HLA-DQBI*0301 (recurrent) HLA-DQBI*0402 (rare allele associated with extensive mucosal invovement)
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ORAL CANCER
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Inflammation is the 7th hallmark of cancer
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chronic inflammatory infiltrate ( inflammatory cells +cytokines)
characterizingchronic disorders
↓
main cause of Tissuemalignancy
It has been suggested that :
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Pathways connectinginflammation & cancers
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• Invasion: Macrophages proteases breakdown the basement membrane around areas of proliferating tumor cells prompting their escape into the surrounding stromal tissue.
• Angiogenesis: macrophages cooperate with tumor cells secreats proangiogenic factors stimulates vascular endothelial cells induce vascular supply.
• Immunosuppression: Macrophages secrete factors that suppress the anti-tumor functions of innate immune system.
• Metastasis: Macrophages associated with tumor vessels secretes factors that guide tumor cells toward blood vessels where they then escape into the circulation..
The Roles of Tumor-Associated Macrophages in Tumor Progression
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The Roles of Tumor-Associated Macrophages in Tumor Progression
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ProstaglandinPromotes Cell Growth
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Differing Functions of COX-1 & COX-2
Arachidonic Acid
COX-1(constitutive)
Homeostasis• Stomach/GI protection• Platelet aggregation• Renal blood flow
COX-2(inducible)
Pathophysiology• Inflammation, Pain• Fever• Cancer• Morbus Alzheimer• Ischemia (CNS)
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Evidence of a COX-2 Dependent Role in NeoplasiaEpidemiological Studies
w Decreased risk of CRC-associated deaths in aspirin users.w The NSAID sulindac decreases the size and number of polyps .w Prostaglandin levels are increased in CR tumors.w Overexpression of COX-2 detected in adenomas and adenocarcinomas.
Animal Studiesw Sulindac and other NSAIDs attenuate intestinal tumor and xenografted cancer cell growth in mice.
Cellular Studiesw Overexpression of COX-2 in epithelial cells results in: Decreased apoptosis Angiogenesis (increased VEFG, FGF, PDGF… expression) Metastatic potential (increased adhesion and MMP expression)
Genetic Modelw Mice defective in COX-2 have a dramatic reduction (86%) in colorectal polyp formation.
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COX-2 is Overexpressed
in Multiple Components of
Cancer
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CONCLUSION Destroy, dilute and wall off any injurious agent & constitutes the
repair. Without inflammation, infections would go unchecked, wounds would never heal, and injured organs may remain as permanent festering sores.
In our day to day lives we come across many cases starting from gingivitis to oral cancer wherein inflammation exerts a direct or an indirect effect.
So understanding inflammation helps us to know the various vascular and cellular changes, mediators involved and therefore help us to evaluate the significance of various anti-inflammatory drugs that we do prescribe, for controlling the same.
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Thank You . . .
“I choose a lazy person to do a hard job.Because a lazy person will find an easy way to do it.”
― Bill Gates
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