NATURE OF CELL & TISSSUE

DEATH, INTRACELLULAR
ACCUMMULATION &
PATHOLOGIC CALCIFICATIONS
DR IZEIN NARUGAYAM CLAUDIUS
DEPT OF ANATOMICAL PATHOLOGY.
NDU
OUTLINES
INTRODUCTION
CELL DEATH- NECROSIS
- APOPTOSIS
- OTHER TYPES
INTRACELLULAR
ACCUMULATION
PATHOLOGIC CALCIFICATION
CELLULAR AGEING
INTRODUCTION:

RESPONSE OF CELL TO INJURY

This depends on the following:
Type, duration and severity of injury
Type , state and adaptability of the injured cell
The response varies from:
Cellular adaptation
Intracellular accumulations
Sub-lethal alterations
Reversible injury (Cell swelling and fatty
change) to
Irreversible injury (or cell death)
INTRODUCTION
INTRODUCTION CONTD
Characteristic of irreversible injury
Rupture of lysosomes and autolysis
Formation of myelin figures
Lysis of Endoplasmic Reticulum
Defects in cell membranes
Formation of large densities
Mitochondrial swelling
Nuclei pyknosis, karyolysis or
karyorrhexis
CELL DEATH
CELL DEATH
Cell death is a state of Irreversible Injury.
It may occur in the living body as a local or
focal change (i.e. autolysis, necrosis and
apoptosis) and the changes that follow it (i.e.
gangrene and pathologic calcification), or
result in end of the life (somatic death).
The morphologic hallmark of cell death is
loss of the nucleus, which occurs via nuclear
condensation (pyknosis), fragmentation
(karyorrhexis), and dissolution (karyolysis),
TYPES OF CELL DEATH
• Necrosis
• Apoptosis
• Necroptosis
• Pyroptosis
• Ferroptosis
• Autophagy
NECROSIS
 Necrosis is a form of cell death in
which cellular membranes fall apart,
and cellular enzymes leak out and
ultimately digest the cell.
 Defined as the morphological changes
that follow cell death or by which cell
death can be recognized in a living
tissue, resulting mainly from the
progressive degradative action of
enzymes on the lethally injured cells.
NECROSIS
 Necrosis is the gross and histologic
(morphology) correlate of cell death
occurring in the setting of
irreversible exogenic injury.
 When cells die, there is leakage of
their contents from their damaged
membrane into the surrounding
tissue which can lead to
inflammation in these tissue.
NECROSIS
The morphologic appearance of necrosis
is the result of denaturation of
intracellular proteins and enzymatic
digestion of the cell.
The enzymes are derived from
1.The lysosomes of the dead cells
themselves-Autolysis
2.The lysosomes of the leucocytes
attracted to the areas during
Inflammation.
 Morphology of necrotic cell

These cells show

 Increased eosinophilia due to:-Loss
of normal basophilia imparted by the
RNA in the cytoplasm and the
increased binding of eosin to
denatured intracytoplasmic proteins.
 A more glassy homogenous
appearance than that of a normal
cells, mainly as a result of the loss of
glycogen particles.
Morphology of necrotic cell

 A vacuolated cytoplasm which

appears moth eaten following
digestion of cytoplasmic organelles by
enzymes.
Calcification of death cells may
occur and
Dead cells may ultimately be replaced
by large, whorled phospholipid masses
called myelin figures.
Morphology of necrotic cell
By electron microscopy , neurotic
cells are characterized by
Overt discontinuities in plasma and
organelle membranes,
Marked dilation of mitochondria with
the appearance of large amorphous
densities,
 Intracytoplasmic mycelium figures,
Amorphous osmiophilic debris and
Aggregates of fluffy material probably
representing denatured proteins
Nuclear changes in necrosis
The nucleus becomes smaller, while
chromatin loses its fine reticular pattern and
become clumped.
Margination of the chromatin adjacent to
the nuclear envelope is an early change.
Changes in the form of one of these patterns
are due to non specific breakdown of DNA.
As DNA is breakdown by endonucleases,
short segments (oligonucleotide fragments)
are formed and phosphoric acid groups
become available for binding to basic dyes
such as hematoxylin.
Nuclear changes in necrosis
The nucleus therefore becomes more
acidic(phospholic acid) and stains
deeply(basophilia).
This process is termed pyknosis- nuclear
shrinkage and increased basophilia. This is also
seen in apoptosis.
The pyknotic nucleus either breaks up into
fragments (karyorrhexis) .
Or its outlines become indistinct as the nuclear
material is broken down(by DNase activity) to
mononucleotides and the phosphoric acid groups
are split off with resultant fading or diminishing in
the basophilia of the nucleic acids(karyolysis).
The cell then becomes ghost of its former self.
Morphology of necrotic cell
Summary of both nuclear and
cytoplasmic changes
Cytoplasmic- Increased Eosinophilia
Nuclear-
Pyknosis
Karryorhexis
Karyolysis
Types of necrosis
Coagulative necrosis
Liquefactive(colliquative)necrosis
Caseous necrosis
Gangrenous necrosis
Fat necrosis
Fibrinoid necrosis
Coagulative Necrosis
This is the primary pattern of denaturation (of
proterns ) which implies -the underlying basic
tissue architectural outline is preserved for at
least several days after death of cells in the
tissue.
The affected tissues exhibit a firm texture (this
is structured necrosis)
In other examples of coagulative necrosis, there
is no residual structure – this structureless
necrosis is well seen in the caseous necrosis of
tuberculosis.
The process of coagulative necrosis with
preservation of the general tissue architecture,
is characteristic of hypoxic death of cells in
Liquefactive necrosis
The dead cells are completely digested,
transforming the tissue into a viscous
liquid that is eventually removed by
phagocytes.
Most often seen in CNS and in
Abscesses.
Liquefaction may occur in an area of
coagulative necrosis as a result of
secondary changes. This is seen in
1. Suppuration e.g. septic infraction
2. Liquefaction of caseous material.
Liquefactive necrosis
Liquefaction necrosis is characteristics
of focal bacterial or occasionally fungal
infections because microbes stimulate
accumulation of inflammatory cells
Colliquative necrosis:
Necrosis with softening. This rarely
occurs as a primary event except in the
CNS. Here necrosis(usually due to
infraction) always results in softening
Caseous Necrosis
Is a particular type of coagulative
necrosis in which the dead tissue has
a firm, cheesy consistency and
contains much lipid material.
Although this type of change may
occur in other conditions, the term
caseation is usually restricted to the
necrosis of tuberculosis.
Unlike coagulative necrosis, the
tissues architecture is completely
effaced or obliterated
Caseous Necrosis
Injured tissue
becomes cheese like
mass of soft tissue
Seen predominantly
in Tuberculous,
fungal, infections

Micro: Amorphous,
granular eosinophilc
material surrounded
by a rim of
inflammatory cells
Gangrenous Necrosis
Gangrenous necrosis is not a distinctive
pattern of cell death but is usually applied to
a limb(generation of lower leg) that has lost
its blood supply and has undergone
coagulation necrosis.
Most often seen on extremities, usually due
to trauma or physical injury
“Dry” gangrene – no bacterial
superinfection; tissue appears dry
“Wet” gangrene – bacterial superinfection
has occurred; tissue looks wet and
liquefactive
Gangrenous Necrosis
DRY GANGRENE WET GANGRENE
Fat necrosis
Fat necrosis is not a specific pattern
of necrosis but is rather a descriptive
term for focal areas of fat destruction.
Seen in fatty tissues - Acute
pancreatitis and breasts
Results from hydrolytic action of
lipases on fat.
Fatty acids released via hydrolysis
react with calcium to form chalky
white areas known as saponification
Fat necrosis
Fibrinoid Necrosis
Usually seen in
the walls of blood
vessels (e.g., in
vasculitides)
Glassy,
eosinophilic fibrin-
like material is
deposited within
the vascular
walls
Osteonecrosis
Necrosis of bone can affect the medullary
bone with its medullary cavity and trabecular
bone or affect both medullary and cortical
bone.
The cause of bone necrosis can be obvious
when it complicates infection or radiation or
radiation damage or ischemic necrosis of
bone from vascular interruption secondary to
trauma, vasculitis, sickle cell anemia,
thrombosis or thromboembolic or nitrogen
embolism,
But in many cases, no obvious cause is
found.
APOPTOSIS
Apoptosis is a pathway of cell death that is
induced by a tightly regulated suicide
program in which cells destined to die activate
intrinsic enzymes that degrade the cells’ own
nuclear DNA and cytoplasmic proteins.
The term Apoptosis is a Greek word meaning
‘falling off’ or ‘dropping off’
It can be physiologic and pathologic.
Characterized by enzymatic degradration of
proteins and DNA.
Initiated by caspases and by recognition and
removal of dead cells by phagocytes.
APOPTOSIS
It involves “step-by-step” gradual
disassembly & phagocytosis of cellular
components, designed to eliminate
unwanted or potentially harmful cells
The dead cell is rapidly cleared before its
contents have leaked out and therefore
apoptotic death does not elicit an
inflammatory reaction in the host
It is an important process in both
health and disease
 Causes of Apoptosis
It occurs in physiological and
pathological conditions, in contrast
with necrosis, which is always
Pathological
PHYSIOLOGIC
Embryogenesis-implantation,
organogenesis, developmental
involution
Hormone-dependent involution in
adults –endometrial cell breakdown
during menstrual cycle, ovarian
Causes of Apoptosis

PHYSIOLOGIC CONTD
Cell deletion in proliferating cell
population e.g. intestinal crypt
epithelia
Death of host cells after they have
served their useful purposes-RBCs,
neutrophils, macrophages
Clonal deletion of self reactive
lymphocytes
Cell death induced by cytotoxic T
lymphocytes
Causes of Apoptosis
PATHOLOGIC
Cell injury with sub-lethal DNA damage
Virally infected cells, e.g. viral hepatitis –
councilman bodies
Cell death in tumours (regression and
actively growing tumours)
Cell death due to chemotherapy and
radiotherapy
Pathological atrophy in parenchymal
organs after duct obstruction (pancreas,
parotid gland)
Morphologic features of apoptosis
The cell condenses(cell shrinkage)
apparently due to loss of water.
Chromatin condensation- the most
characteristic feature of apoptosis,
under the nuclear membrane into dense
masses of various shapes and sizes
Formation of cytoplasmic blebs and
apoptotic bodies. The cell first show
extensive surface blebing ,then
undergoes fragmentation into
membrane – bound apoptotic bodies
Morphologic features of apoptosis
Phagocytosis of apoptotic cells or
cell bodies usually by
macrophages= the cells are rapidly
degraded within lysosomes and
adjacent healthy cells proliferate to
replace the space.
Also neighboring epithelial cells
participate in elimination of apoptotic
bodies by incorporating them into
lysosomes. Apoptotic bodies derived
from epithelial cells lining free
 Biochemical features of apoptosis
Protein Digestion (Caspases)
DNA breakdown
Phagocytic Recognition
Protein cleavage- inactive pro-enzyme of the
family of cysteine proteins are activated into
caspases which induce apoptosis by
1. Cleaving many vital cellular proteins, such as
laminins and thus breakup the nuclear scaffold
and cytoskeleton
2. Activating DNases which degrade nuclear DNA.
These changes under lie the nuclear and
cytoplasmic structural attentions seen in
apoptotic cells.
 Biochemical features of apoptosis
DNA breakdown- there is breakdown
of DNA into large 50 to 300- kilobase
pieces a characteristic of apoptotic
cells.
Subsequently, there is
internucleosomal cleavage of DNA into
oligonueclosomes, in multiples of 180-
200 base pairs.
Internucleosomal cleavage is not
specific to apoptosis.
 Biochemical features of apoptosis
Phagocytic recognition- some
apoptotic cells express
phosphatidylserine in the outer layers
of the plasma membrane while in some
types of apoptosis, thrombospondin, an
adhesive glycoprotein is also
expressed on the surface of apoptotic
bodies and other proteins secreted by
phagocytes may bind to apoptotic cells
and opsonize the cells for
phagocytosis.
 Mechanism of apoptosis
The process of apoptosis is divided into two
phases
Initiation phase- during which caspases
become catalytically active
Execution phase- during which these
enzymes act to cause death.
Initiation of apoptosis occurs principally by
signals from two distinct but convergent
pathways- the Extrinsic or Death
receptor-initiated pathway and the
Intrinsic or Mitochondrial pathway.
Both pathways converge to activate caspases
 Mechanism of apoptosis.
 The extrinsic pathway- this is the
death receptor initiated pathway.
 Death receptors are members of the TNF
receptors family that contain a cytoplasmic
domain.
 The death domain is essential for delivering
apoptotic signals.
 The best-known death receptors are the type
1TNF receptor(TNFR1) and a related protein
called Fas(CD95).
The extrinsic pathway-
When Fas is cross-linked by its ligand Fas 1,
three or more molecules of Fas come together
and their cytoplasmic death domains form a
binding site for an adapter protein that also
contains a death domain and is called FADD(fas
associated death domain).
FADD attached to the dead receptors in turn
binds an inactive form of capase-10(in humans),
again via a death domain: multiple pro-caspase-
10 are brought into proximity and they cleave one
another to generate active caspase-10.
There is then autocatalytic activation of capases
by cleaving and the active enzymes mediate
execution phase of apoptosis.
The extrinsic pathway-
This pathway of apoptosis can be
inhibited by a protein called FLIP
which binds to pro-capases- 10 but
cannot cleave and activate the
enzymes because it lacks enzymatic
activity.
Some viruses and normal cells
produce flip and use this inhibitor to
protect infected and normal cells from
Fas- mediated apoptosis.
Note- FasL(CD95 Ligand)is produced
The extrinsic (death receptor – initiated) pathway
of apoptosis, illustrated by the events following Fas
engagement.
 The intrinsic (mitochondrial)pathway
Here there is no role for death receptors,
rather there is increased mitochondrial
permeability and release of pro-apoptotic
molecules into the cytoplasm.
Two main anti-apoptotic members of the Bcl-
2 family of protein which normally reside in
the mitochondrial membranes and the
cytoplasm are Bcl-2 and Bcl-x.
When cells are deprived of survival signals
or subjected to stress, BCL-2 and/or Bcl-x are
lost from the mitochondrial membrane and
are replaced by pro-apoptotic members of
the family such as BaK, BaX and Bim
The intrinsic (mitochondrial)pathway
When Bcl-2/Bcl-x levels decrease, the
permeability of the mitochondrial membrane
increases and several proteins that can
activate the capases cascade leak out.
One of these proteins is cytochrome C, well
known for its role in mitochondrial
respiration.
In the cytosol, cytochrome C binds to a
protein called Apaf-1(apoptosis activating
factor-1) and the complex activates caspase-9.
Note that Bcl-2 and Bcl-x may directly inhibit
Apaf-1 activation, and their loss from cells
may permit activation of Apaf-1
The intrinsic (mitochondrial)pathway
Also other mitochondrial proteins, such as
apoptosis inducing factor(AIF), enter the
cytoplasm where they bind to and neutralize
various inhibitors of apoptosis, whose normal
function is to block caspase activation(e.g.
FLIP).
The net result is the initiation of a caspase
cascade.
The two pathways overlaps in places
including in hepatocytes where Fas
signaling activates a pro-apoptotic member
of the Bcl family called Bid, which then
activates the mitochondrial pathway
 The execution phase
This final phase of apoptosis is mediated by a
proteolytic cascade, to which the various
initiating mechanisms converge.
Caspases is based on two properties ‘c’ -cysteine
protease and ‘caspase’- unique ability of these
enzymes to cleave after aspartic acid residue.
The caspase family are divided functionally into
two basic groups- initiator and executioner-
depending on the order in which they are
activated during apoptosis.
Initiator caspases- caspase-8(elegans.c.)
caspase-10(humans), caspase-9.
Executioner caspases- caspases-3 and 6.
 The execution phase
After an initiator caspase is cleaved to
generate its active form, the enzymatic
death program is set in motion by
rapid and sequential activation of
other caspases.
Executioner caspases act on many
cellular components.
They cleave cytoskeletal and nuclear
matrix proteins and thus disrupt the
cytoskeleton and lead to break down of
the nucleus.
Removal of dead cells
Apoptotic cells and their fragments
have marker molecules on their
surfaces, cells on their surfaces which
facilitate early recognition by
adjacent cells or phagocytes for
phagocytic uptake and disposal.
In addition, macrophages can also
secrete substances that bind
specifically to apoptotic but not live
cells and opsonize these cells for
phagocytosis.
Removal of dead cells
Note
Viable cells appear to prevent their own engulfment by
macrophages through expression of certain surface
molecules e.g. CD31 the tumor- suppressor gene p53.
P53 accumulates when DNA is damaged and arrests the
cell cycle (at G1 phase) to allow time for repair.
If DNA repair fail, p53 trigger apoptosis. If p53 is
absent or is mutated (as in certain cancers) it is
incapable of inducing apoptosis and favors cell survival.
Thus p53 serve as crucial ‘life and death’ switch in case
of genotoxic stress.
 P53 triggers the distal death effector machine by
stimulation of several pro-apoptotic members of the Bcl
family , notably BaX and Bak as well as Apaf-1. These
proteins activate caspases and cause apoptosis
Other Apoptotic Mech.
1. Apoptosis induce by TNF family
of receptors
Apoptosis imitated by Fas-fasl
coupling is important in the
elimination of lymphocytes that
recognized self-antigens, and
mutations in Fas or Fasl result in
autoimmune diseases in humans and
mice.
2. Cytotoxic T- lymphocytes- mediated
Apoptosis:
CTLs recognize foreign antigens presented on
the surface of infected host cells. On
recognition, CTLs secrete perforin, a
transmembrane pore-forming molecule , which
allows entry of the CTL granule serine protease
called Granzyme B.
Granzyme B has the ability to cleave proteins
at aspartate residues and is able to activate a
variety of other caspases.
This way, CTLs kill target cells through by
passing the upstream signaling events and
directly induce the effector phase of apoptosis.

Dysregulated apoptosis
1. Disorders associated with defective apoptosis
and increased cell survival; these give rise to
Cancers especially tumors with P53 mutations or
hormone dependent tumors e.g. breast, prostrate
and ovarian cancers
Automine disorders
2. Disorders associated with increased
apoptosis and excessive cell death . examples
Nondegenerative diseases manifested by loss of
specific sets of neurons such s spinal muscular
atrophies
Ischemic injury as in MI and stroke and
Death of virus-infected cells in many viral
infection.
APOPTOSIS Vs. NECROSIS
Fundamental differences between
Necrosis and Apoptosis
NECROSIS APOPTOSIS

Loss of membrane integrity Intact plasma membrane

Enzymatic digestion of Intracellular enzyme do not leak out or

surrounding cells digest or digest surrounding cells

Elicits host reaction- Not attended by inflammatory rxn

inflammation
Necrosis is invariably Often physiologic ,means of eliminating
pathologic (culmination of unwanted cells; may be pathologic after
irreversible cell injury) some forms of cell injury especially DNA
damage

Nucleus undergoes pyrosis= Fragmentation into nucleosome size

karyorrhexis =karyolysis fragments

The cell size is Reduced(shrinkage)

 NECROPTOSIS
This form of cell death is an hybrid that
share aspects of both necrosis and
apoptosis.
Necroptosis resembles necrosis
morphologically and Apoptosis
mechanistically as a form of program
cell death.
Its triggered by ligation of TNFR1,and
viral proteins of RNA and DNA viruses
Its caspase-independent but dependent
on signalling by RIP1 and RIP3 complex.
PYROPTOSIS
• Is another form of programmed cell
death.
• This is so called because it is
accompanied by the release of fever
inducing cytokine IL-1 and because it
bears some biochemical similarities
with apoptosis.
• It occurs in cell infected by microbes
• It involves activation of caspase-1
which cleaves the precursor form of IL-
1 to generate biologically active IL-1.
Ferroptosis.
Discovered in 2012.
It is a distinct form of cell death that is
triggered when excessive intracellular levels
of iron or reactive oxygen species overwhelm
the glutathione-dependent antioxidant
defenses to cause unchecked membrane lipid
peroxidation.
The overall effect is the loss of plasma
membrane permeability, which ultimately
leads to cell death resembling necrosis
The most important features are the loss of
mitochondrial cristae and ruptured outer
AUTOPHAGY
Is a process in which a cell eats
its own contents.
It involves the delivery of
cytoplasmic materials to the
lysosomes for degradation.
Its an adaptive response that is
enhanced during nutrient
deprivation, allowing the cell to
cannibalize itself to survive.
INTRACELLULAR
ACCUMULATIONS
INTRACELLULAR ACCUMULATIONS
Intracellular accumulation of abnormal
amounts of certain substances is one of
the manifestations of metabolic
derangements.
These accumulations may be located in the
Cytoplasm,
Within organelles (eg lysosomes),
 The nucleus,
They may be composed of substances that
are synthesized by the affected cells or
are produced elsewhere.
Mechanisms(Processes) of Accumulation
There are four(4) main mechanisms
leading to abnormal intracellular
accumulations
Inadequate removal of a normal
substance secondary to defects in
packaging and transport, as in fatty
change-Steotosis.
Accumulation of an endogenous
substance as a result of genetic or
acquired defects in its folding, packaging,
transport, or secretion, as with certain
mutated forms of α1-antitrypsin.
Mechanisms(Processes) of Accumulation
 Failure to degrade a metabolite due
to inherited enzyme deficiencies,
typically lysosomal enzymes(lysosomal
storage diseases)
Deposition and accumulation of an
abnormal exogenous substance
when the cell has neither the enzymatic
machinery to degrade the substance
nor the ability to transport it to other
sites( Accumulation of carbon or silica
particles)
Categories Of Intracellular Accumulation

There are basically three(3)

categories:
Normal cellular components in
excess e.g. water, lipids, protein,
carbohydrate
Abnormal substances either
exogenous (minerals or products of
infections) or endogenous
(products of abnormal synthesis or
metabolism)
Fatty changes(steastosis)
This term describes abnormal accumulations
of triglycerides within parenchymal cells.
Its often seen in the liver because it’s the
major organ of fat metabolism, but also
occurs in the heart, muscle , and kidney.
Causes
Alcohol abuse.
Toxins
Protein malnutrition
Diabetes M
Obesity
Anoxia
The commonest cause of fatty
change in the liver in
industrialized west is alcohol
abuse
Mild fatty change- no effect on
cellular function
More severe fatty change e.g. in
CCL4 poisoning – impair cellular
function Nonalcoholic steatohepatitis
and non alcoholic fatty liver disease
may lead to cirrhosis and even liver
cancer.
Morphology liver-
enlarged, may
weigh up to 3-6 kg.
yellow, soft and
greasy

Microscopy- small
vacuoles in the
cytoplasm around
the nucleus
Cholesterol and cholesterol esters
Most cells use cholesterol for the synthesis of
cell membranes without intracellular
accumulation of cholesterol or cholesterol
esters because cellular metabolism of
cholesterol is tightly regulated.
Accumulation of cholesterol however is seen in
several pathologic processes and is manifested
histologically by intracellular vacuoles.
Pathologic Processes
Atherosclerosis – in atherosclerotic plagues,
smooth layer of the aorta and large arteries are
fitted with lipid vacuoles, most of which are
made up of cholesterol and cholesterol esters.
these cells are called foam cells.
Xanthomas- clusters of foamy cells in the
subepithelial connective tissue of the skin
and in tendons, producing tumors masses.
Inflammation and Necrosis- foamy
macrophages are frequently seen at sites of
cell injury and inflammation.
Cholestrolosis- focal accumulations of
cholesterol laden macrophages in the
lamina propria of gall bladder.
Niemann- pick diseases, type c-
lysosomal storage disease in which an
enzyme involved in cholesterol trafficking is
mutated and hence cholesterol
accumulation in multiple organs
PROTEINS
Intracellular accumulation of proteins
usually appear as rounded, eosinopohilic
droplets, vacuoles or aggregates in the
cytoplasm.
Examples in amyloidosis- proteins deposit
in extracellular space .
Protein accumulation can be caused by
Reabsorption droplets in the proximal renal
tubules
Synthesis of excessive amounts of normal
secretory - in active synthesis of
immunoglobins
 Defects in protein folding- in the process of
proper configuration of polypeptide chains of
proteins(protein folding) partially folded
intermediated arise and these may form
intracellular aggregates among themselves or by
entangling other proteins. Usually these
intermediates are stabilized by a number of
molecular chaperones, which interact with proteins
directly. Chaperones aid in proper folding and in
transport across the ER, Golgi complex and beyond,
these chaperones are synthesized normally or
induced by stress(heat-shock proteins e.g. hspto,
hspqo, ubiquitin).
If folding process is not successful, the chaperones
facilitates degradation of the damaged protein. The
degradative process often involves ubiquitin which
is added to the abnormal protein and marks it for
Mechanisms by which protein folding defects
can cause intracellular accumulations or
result in disease include
Defective intracellular transport and
secretion of critical proteins e.g. alpha-1
antitrypsin deficiency in which mutations in the
protein leads to build- up of partially folded
intermediates such that the resultants deficiency
in the circulating enzyme causes emphysema.
In cystic fibrosis, mutations delays
disassociation of a chloride channel protein from
one of its chaperones, resulting in abnormally
folding and loss of function. In familial
hypercholesterolemia, mutation in low density
lipoprotein receptor interfere with proper folding
of receptor proteins.
ER stress induced by unfolded and
misfolded proteins . Unfolded or misfolded
proteins accumulated in the ER and trigger a
number of cellular responses, collectively
called the unfolded protein response,
activation of the unfolded protein response
also leads to cell death by activating caspases,
particularly an ER- RESIDENT CASPASE
Called caspase -12.
Examples -Alzheimer’s , Huntington’s and
Parkinson’s disease and possibly type 11 DM
are neurodegenerative disease in which there
is aggregation of abnormally folded proteins,
caused by genetic mutations, aging, or
unknown environmental factors.
Aggregation of abnormal proteins-
these are called proteinopathies or
protein aggregation diseases. The
deposits can be intracellular,
extracellular or both e.g. certain form
of Amyloidosis
HYALINE CHANGE
Refers to an alteration within cells or in
the extracellular space Homogenous
glassy pink appearance
Descriptive histological --pink appearance
in routine H and E stain.
Produced by a variety of alterations

e.g. Intracellular accumulation of Protein

in renal tubules, Russell bodies, Mallory
bodies
Extracellular hyaline in old scars, walls of
arterioles in hypertension and Diabetes
GLYCOGEN
Excessive accumulations are seen in patients with
abnormality in either
Glucose or glycogen metabolism
Appear as clear vacuoles within the cytoplasm
(stained best with carmine or PAS)
e.g. In DM, glycogen is found in epithelial cells of
distal portion of proximal convoluted tubules, liver
cells, heart muscle and B-cells of islets of
Langerhans
In Glycogen Storage Diseases(group of closely
related genetic disorders) glycogen accumulates
within cells
Result from enzyme defects in synthesis or
breakdown of glycogen or massive accumulation
PIGMENTS
Coloured substances either normal
constituents of cells or abnormal
Can be exogenous or endogenous
Exogenous ones include:
1. Carbon or coal dust- alveoli regional
lymph node. In lungs  anthracosis
2. In cold mines  fibroblastic reaction or
emphysema coal workers’
pneumoconiosis
3. Tattooinglocalized to skin  lifelong (No
inflammatory reaction)
Endogenous include:
Lipofuscin(Lipochrome, wear and tear
pigment or aging pigment)
Composed of polymers of lipids and
phospholipids complexed with protein
Derived through lipid peroxidation of
polyunsaturated lipids
Teltale sign of free radical injury peroxidation
Appear as yellow-brown (brown lipid)
Seen in cells undergoing slow regressive
changes (liver and Heart)
E/M granules of highly electron dense, with
membranous structure and in a perinuclear
location
MELANIN
Brown-Black endogenous, non-haemoglobin
derived pigment
Formed when tyrosinase catalyses the
oxidation of tyrosine to
dihydroxyphenylalamine in melanocytes
Another brown-black pigment is
HOMOGENTISIC ACID (occurs in patients
with alkaptonuria) deposit in small
connective tissue, cartilage known as
Ochronosis
Special stain is Mason-Fontana (Black)
HAEMOSIDERIN
Haemoglobin-derived, golden-yellow to brown
granular or crystalline
Transported with transferrins
Stored in association with apoferritinferritin
micelles
Ferritin forms hemosiderin granules when excess
Found in small amounts in cells engaged with red
cell breakdown (Bone marrow, spleen and liver)
Systemic overload haemosiderosis
Seen in increased absorption of dietary Iron,
impaired use of iron, haemolytic anaemia and
transfusion
Appear in liver, pancreas and kidney
Stained by Perl’s
Prussian Blue
blue colour
Impair organ
function is seen
with
Haemachromat
osis organ
damage

Haemosiderin/
Melanin
PATHOLOGIC CALCIFICATION
PATHOLOGIC CALCIFICATION
This is defined as the abnormal
deposition of calcium salts, together
with smaller amounts of iron,
magnesium and other mineral salts on
tissues.
Two forms of pathologic calcification
occur:
Dystrophic calcification and
Metastatic calcification.
Dystrophic calcification
This is the deposition of calcium salts in dead, or
degenerated tissue.
Here, calcium deposits are localized, the plasma
levels of calcium and phosphate are normal and
there is no derangement in calcium metabolism.
Calcification in dead tissues are seen in the
following conditions.
1. Caseous material: calcification is of frequent
occurrence in caseous material and remains as
permanent landmark of previous tuberculous
infestation . Its seen in healed Ghon foci and
associated lymph nodes and also in the
mesenteric nodes of primary intestinal infection.
Calcification is also seen in healed lesions of
2. Dead parasites- many parasites
undergo calcification, but this occurs
only after their death. Examples;
Schistosoma ova, hydatid cysts,
trichinellaspiralis and lesions of
cysticercosis. The calcified dead fetus
(lithopedion) may be included under
this heading.
3. Fat necrosis: seen after acute
pancreatitis as well as in traumatic
lesions of the breast.
4. Infracts: some infracts have a peculiar
tendency to undergo calcification, infracts in the
rat kidney invariably calcify.
5. Thrombi in veins may calcify to produce
phleboliths; these are quite commonly seen
radiologically in the pelvic veins. Arterial thrombi
are less liable to calcification.
6. Hematomas; although collections of blood in
any situation may undergo calcification, this is
particularly common when hematoma is in close
association with bone. E.g. traumatic subdural
hematoma. In traumatic myositis ossificans,
there is calcification and subsequent ossification
of hematoma in a muscle.
Calcification in degenerate tissues
1. Scars : The fibrous tissue of scars may undergo
hyaline degeneration and subsequent
calcification.
2. Chronic inflammatory granulation tissue:
Dystrophic degenerate tissue of chronic
inflammatory lesions. Its seen in the walls of
chronic abscesses. Its prominent in aging heart
valves and in damaged(scarred) valves of
rheumatic heart disease and healed infective
endocardiditis.
3. Atheroma, calcification in the degenerate tissue
of atherosclerosis occurs frequently in the aorta
or coronary vessels. This occurs in the intima as
distinct from medial lesions of Monckebreg
sclerosis.
4. Monckeberg’s sclerosis: the hyalinized tunica
media in this condition regularly becomes calcified,
thereby converting the artery into a rigid tube. The
calcified tissues is disposed in the form of rings, as
it has the same distribution as the muscle coat it
replaces. The cause is unknown though loss of
autonomic interaction may be responsible for the
frequency of the disease in diabetic subjects with
neuropathy.
5. Serial degenerate tissue: calcification occurs
in
i. Coastal cartilages of elderly people
ii. Dura Mata in old age and other examples.
6. Degenerate colloid goiters and so called
adenomas of thyroid -flecks of calcification are
present in many modular goiters. This may be of
value in detection or retrosternal goiters.
Cysts
Many cysts of long- standing show calcification
of their walls. Good examples are epidermoid
and Pilar cysts of the skin.
Degenerate tumors
Examples – large uterine fibroids, often undergo
extensive calcification, usually after the muscle
element has undergone necrosis and become
replaced by hyaline fibrous tissue. Some tumors
show circumscribed spherules of calcification
calcospherites( e.g. psammoma bodies of
meningiomas. Also seen in cystadenoma and
cystadenocarcinoma of the ovary and in
papillary adenocarcinoma of thyroid.
Chondrocalcinosis
Deposition of calcium pyrophosphate crystals in
cartilage. Fibrocartilage most commonly
involved are menisci of the lane , and triangular
cartilage f the wrist.
Sundry lesions
1. Pulmonary alveolar microlithiasis where
calcified laminated structure are found in the
alveoli. Similar to copora amylacea in prostrate
2. Calcinosis universalis- a rare manifestation of
systemic sclerosis or dermatomyositis
3.Tumoralcalcinosis, in which there are large
calcareous swellings in the subcutaneous tissues
near the larger joints e.g. elbos, shoulders,
knees. Its familial and is seen more in black
Morphology of dystrophic calcification
Microscopically, calcium salts appear as
granular deposits which stain a very deep blue
color with hematoxylin in the usual H and E
section.
They can be intracellular , extracellular or both.
Heterotrophic bone may be formed in the focus
of calcification and conditions maintained above
Pathogenesis
The final common pathway in the pathogenesis
of dystrophic calcification is the formation of
calcium deposits in the form of
hydroypatitic(similar to hydroxypatites of bone).
This involves two processes. Initiation and
propagation extracellularly.
 Metastatic calcification
Metastatic disposition of calcium salts in
otherwise normal tissues almost always
results from hypercalcemia caused by
abnormal metabolism of calcium and
phosphate.
Common type (following
hyperparathyroidism)
The calcium salts are truly metastatic
being derived from bone, but there are
other conditions in which the excess
calcium is absorbed from the gut.
Causes of metastatic calcification
1. Hyperparathyroidism caused by
Hyperplasia(primary or secondary)
Parathyroid tumors
Secretion of PTH- related protein by
malignant tumors e.g. oat cell Ca of the lung
2. Destructive bone lesions
Primary tumors of bone marrow(e.g.
multiple myeloma, leukemia)
Diffuse skeletal metastasis(e.g. breast
cancer)
Accelerated bone turnover(e.g. Paget
disease)
3. Excessive absorption of calcium from the
bowel
Hypervitaminosis of D (vit. D intoxication)
Vit. D -sensitive states e.g. idiopathic
hypercalcemia of infancy(Williams syndrome)
characterized by abnormal sensitivity to Vit. D
4. Renal failure: cause retention of phosphate ,
leading to secondary hyperparathyroidism
Often less common causes include;
5. Aluminum intoxication: which occurs in
patients on chronic renal dialysis
6. Milk-alkali syndrome-Which is due to
excessive ingestion of calcium and absorbable
antacids such as milk or calcium
carbonate(compulsive milk drinking)
Organs involved
Metastatic calcification may occur widely
throughout the body but principally affects
The intestinal tissues of the gastric
mucosa- especially the fundal gland. As
these glands secrete HCL, the tissues are
left relatively alkaline and this favors
calcification.
Kidneys
Lungs
Systemic arteries
Pulmonary veins
Kidneys
This is the most frequent and important
site.
Deposition occurs especially around the
tubules, where severe damage is produced.
This condition is called nephrocalcinosis,
and it may lead to renal failure.
All of these tissues lose acid and therefore
have an internal alkaline compartment that
predisposes them to metastatic
calcification.
CELLULAR AGEING
CELLULAR AGEING
Cellular aging is the result of a progressive decline in
the life span and functional activity of cells.
Individuals age because their cells age.
Abnormalities are thought to be due to:
 Accumulation of mutations in nuclear and mitochondrial
DNA;
 Decreased cellular replication progressing to
Replicative senescence;
 Defective protein homeostasis;
 Calorie restriction which serves to improve immunity,
slows down growth which allows for better protein
homeostasis, DNA replication and repairs;
 Persistent inflammation;
 Lack of Physical exercise
 Stress.
CELLULAR AGEING
The Role of the Telomere
Telomeres are short repeated
sequences of DNA present at the ends
of chromosomes that are important
for ensuring the complete replication
of chromosome ends and for
protecting the ends from fusion and
degradation;
Replicative senescence is related to
Telomere shortening which is usually
maintained in health by the
Telomerase enzyme.
The Role of the Telomere
Telomere shortening also may decrease
the regenerative capacity of stem
cells, further contributing to cellular
aging.
Abnormalities in telomere maintenance
have been implicated in many
diseases, such as aplastic anemia and
other cytopenias, premature greying
of hair, skin pigment and nail
abnormalities, pulmonary and liver
fibrosis, and others.
The most effective way to prolong life
is calories restriction because of a
family of proteins called SIRTUINS.
 These have histone deacetylase activity
and promote expression of genes whose
products increase longevity.
 The best-studied mammalian sirtuin is
Sirt-1Q which has been shown to
improve glucose tolerance and enhance
β-cell insulin secretion.
 It is implicated in diabetes.
 A defect in DNA helicase enzyme
(required for DNA replication and
repair) results in premature ageing
(WERNER SYNDROME).
 Decreased activity of telomerase is
associated with ageing whereas its
excessive activity is associated with
cancers.
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