Discussion Board

B R I E F C O N T E N T S

UNIT I Pathophysiologic Processes

1 Introduction to Pathophysiology, 1

2 Homeostasis, Allostasis, and Adaptive Responses to Stressors, 12

UNIT II Cellular Function

3 Cell Structure and Function, 26

4 Cell Injury, Aging, and Death, 59

5 Genome Structure, Regulation, and Tissue Differentiation, 77

6 Genetic and Developmental Disorders, 94

7 Neoplasia, 117

UNIT III Defense

8 Infectious Processes, 141

9 Inflammation and Immunity, 158

10 Alterations in Immune Function, 194

11 Malignant Disorders of White Blood Cells, 215

12 HIV Disease and AIDS, 233

UNIT IV Oxygen Transport, Blood Coagulation, Blood Flow, and Blood Pressure

13 Alterations in Oxygen Transport, 259

14 Alterations in Hemostasis and Blood Coagulation, 298

15 Alterations in Blood Flow, 313

16 Alterations in Blood Pressure, 337

UNIT V Cardiac Function

17 Cardiac Function, 354

18 Alterations in Cardiac Function, 382

19 Heart Failure and Dysrhythmias: Common Sequelae of Cardiac Diseases, 411

20 Shock, 434

UNIT VI Respiratory Function

21 Respiratory Function and Alterations in Gas Exchange, 451

22 Obstructive Pulmonary Disorders, 478

23 Restrictive Pulmonary Disorders, 499

UNIT VII Fluid, Electrolyte, and Acid-Base Homeostasis

24 Fluid and Electrolyte Homeostasis and Imbalances, 521

25 Acid–Base Homeostasis and Imbalances, 541

UNIT VIII Renal and Bladder Function

26 Renal Function, 551

27 Intrarenal Disorders, 575

28 Acute Kidney Injury and Chronic Kidney Disease, 593

29 Disorders of the Lower Urinary Tract, 609

UNIT IX Genital and Reproductive Function

30 Male Genital and Reproductive Function, 626

31 Alterations in Male Genital and Reproductive Function, 641

32 Female Genital and Reproductive Function, 656

33 Alterations in Female Genital and Reproductive Function, 671

34 Sexually Transmitted Infections, 689

UNIT X Gastrointestinal Function

35 Gastrointestinal Function, 697

36 Gastrointestinal Disorders, 720

37 Alterations in Function of the Gallbladder and Exocrine Pancreas, 742

38 Liver Diseases, 754

UNIT XI Endocrine Function, Metabolism, and Nutrition

39 Endocrine Physiology and Mechanisms of Hypothalamic-Pituitary Regulation, 783

40 Disorders of Endocrine Function, 799

41 Diabetes Mellitus, 815

42 Nutritional and Metabolic Disorders, 838

UNIT XII Neural Function

43 Structure and Function of the Nervous System, 850

44 Acute Disorders of Brain Function, 891

45 Chronic Disorders of Neurologic Function, 915

46 Alterations in Special Sensory Function, 936

47 Pain, 955

UNIT XIII Neuropsychological Function

48 Neurobiology of Psychotic Illnesses, 971

49 Neurobiology of Nonpsychotic Illnesses, 989

UNIT XIV Musculoskeletal Support and Movement

50 Structure and Function of the Musculoskeletal System, 1001

51 Alterations in Musculoskeletal Function: Trauma, Infection, and Disease, 1020

52 Alterations in Musculoskeletal Function: Rheumatic Disorders, 1042

UNIT XV Integumentary System

53 Alterations in the Integumentary System, 1058

54 Burn Injuries, 1093

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• Review questions with rationales.

• Key Points.

• Glossary with audio pronunciations.

• Answers to key questions.

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2015v1.0

PATHOPHYSIOLOGY TH EDITION6

JACQUELYN L. BANASIK, PhD, ARNP Associate Professor College of Nursing

Washington State University Spokane, Washington

LEE-ELLEN C. COPSTEAD, PhD, RN Professor Emerita

Department of Nursing College of Nursing and Health Sciences

University of Wisconsin—Eau Claire Eau Claire, Wisconsin

3251 Riverport Lane St. Louis, Missouri 63043

PATHOPHYSIOLOGY, SIXTH EDITION ISBN: 978-0-323-35481-3

Copyright © 2019 by Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2013, 2010, 2005, 2000, and 1995.

International Standard Book Number: 978-0-323-35481-3

Executive Content Strategist: Kellie White Content Development Specialist: Jennifer Wade Publishing Service Manager: Jeffrey Patterson Book Production Specialist: Carol O’Connell Book Designer: Renee Duenow

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To:

Loved ones, past and present,

who give meaning to the work.

JLB

This page intentionally left blank

vii

Brent A. Banasik, PhD, MA, BS Scientist Chemistry Banasik Consulting Seattle, Washington

Brianne N. Banasik, BS Environmental Science, MS Marine Resources Management

Research Associate Pediatric Vaccinology University of Texas Medical Branch Galveston, Texas

Jacquelyn L. Banasik, PhD, ARNP Associate Professor College of Nursing Washington State University Spokane, Washington

Robin Y. Beeman, BSN, MSN, PhD Chair and Professor Nursing University of Wisconsin—Eau Claire Eau Claire, Wisconsin

Cheryl L. Brandt, PhD, RN, ACNS-BC Professor College of Nursing and Health Sciences University of Wisconsin—Eau Claire Eau Claire, Wisconsin

Ann Futterman Collier, PhD Associate Professor and Chair Psychological Sciences Northern Arizona University Flagstaff, Arizona

Lee-Ellen C. Copstead, PhD, RN Professor Emerita Department of Nursing College of Nursing and Health Sciences University of Wisconsin—Eau Claire Eau Claire, Wisconsin

Carol L. Danning, MD Staff Rheumatologist Rheumatology Department Gundersen Health Systems La Crosse, Wisconsin

Michael R. Diestelmeier, MD Fellow American Academy of Dermatology Dermatologist, Retired Mayo Clinic Health System Eau Claire, Wisconsin

Ruth E. Diestelmeier, RN, MSN Clinical Instructor Department of Nursing University of Wisconsin—Eau Claire Eau Claire, Wisconsin

C O N T R I B U T O R S

Roberta J. Emerson, PhD, RN Associate Professor, Retired Washington State University College of Nursing Spokane, Washington

Linda Felver, PhD, RN Associate Professor School of Nursing Oregon Health & Science University Portland, Oregon

Rosemary A. Jadack, PhD, RN Professor Nursing University of Wisconsin—Eau Claire Eau Claire, Wisconsin

Debra A. Jansen, PhD, RN Associate Dean, Professor College of Nursing and Health Sciences University of Wisconsin—Eau Claire Eau Claire, Wisconsin

Marie L. Kotter, PhD, MS, BS Professor Emeritus Health Sciences Weber State University Ogden, Utah

Teresa Grigsby Loftsgaarden, MSN, RN, OCN,ONN-CG

Oncology Nurse Navigator Regional Cancer Center Sacred Heart Hospital Eau Claire, Wisconsin

Joni D. Marsh, BSN, MN Advanced Registered Nurse Practitioner Medical Oncology Summit Cancer Centers Spokane, Washington

Benjamin J. Miller, PhD, ARNP, FNP-C, ACNPC, ENP-C

Assistant Professor Seattle University Seattle, Washington

Sarah Ogle, DO, MS Banner University Medical Center-Phoenix University of Arizona College of Medicine

Phoenix Phoenix, Arizona

Nirav Patel, MD Assistant Professor, Infectious Diseases and

Critical Care Medicine Internal Medicine Saint Louis University School of Medicine; Chief Medical Officer SSM Health Saint Louis University Hospital; Infection Control Officer/Director of

Antibiotic Stewardship SSM Health Saint Louis University Hospital Saint Louis, Missouri

Faith Young Peterson, BSN, MSN, MPA, CFNP

Family Nurse Practitioner Marsing, Idaho

Cheryl Rockwell, RN, MSN Clinical Assistant Professor Nursing Department Indiana University-Purdue University at

Fort Wayne; Staff/Clinical Nurse Surgical Trauma Intensive Care Unit Parkview Health Systems Fort Wayne, Indiana

Samantha Cody Russell, Psychology, MA Graduate Student Psychological Sciences Northern Arizona University Flagstaff, Arizona

Jeffrey S. Sartin, MD Consulting Physician Infectious Diseases Infectious Disease and Epidemiology

Associates; Consulting Physician Infectious Diseases Nebraska Medicine; Consulting Physician Infectious Diseases CHI Hospitals Omaha, Nebraska

Lorna L. Schumann, PhD Heritage UGM Women and Children’s

Clinic Medical Clinic Heritage Health Coeur d’Alene, Idaho

Susan G. Trevithick, RN, MS, NE-BC Compliance Officer VA Salt Lake City Healthcare System Salt Lake City, Utah

Marvin Van Every, MD Staff Urologist Urology Department Gundersen Health Systems La Crosse, Wisconsin

Linda D. Ward, PhD, FNP-C Assistant Professor College of Nursing Washington State University Spokane, Washington

viii

Brianne N. Banasik, MS Research Associate Pediatric Vaccinology University of Texas Medical Branch Galveston, Texas

Deb Cipali, RN, BSN, MSN, EdD(c) Des Moines Area Community College Nursing Lab Coordinator/Adjunct Professor Ankeny, Iowa

Janie Corbitt, RN, MLS Milledgville, Georgia

Maria Fleurdeliz Cuyco, BS Instructor Preferred College of Nursing Los Angeles, California

Abimbola Farinde, PhD Professor Columbia Southern University Orange Beach, Alabama

Annette Gunderman, DEd, MSN, RN Associate Professor of Nursing Bloomsburg University Bloomsburg, Pennsylvania

Barbara Hunter, RN, MSN School of Nursing, Klamath Falls Campus Oregon Health & Science University Klamath Falls, Oregon

Sandra L. Kaminski, MS, PA-C Assistant Professor Seton Hall University School of Health and Medical Sciences; Physician Assistant VA NJ Healthcare System Medical Service/Infections Disease Clark, New Jersey

Steven Krau, PhD, RN, CNE Associate Professor Vanderbilt School of Nursing Nashville, Tennessee

Clarice Perry, MS Research Associate Pediatric Vaccinology University of Texas Medical Branch Galveston, Texas

R E V I E W E R S

Janet Pinkelman, MSN, RNC-Maternal Newborn Nursing

Professor of Nursing Owens Community College Toledo, Ohio

Linda Turchin, RN, MSN, CNE Associate Professor of Nursing Fairmont State University Fairmont, West Virginia

Kim Webb, MN, RN Adjunct Nursing Instructor Pioneer Technology Center Ponca City, Oklahoma

Janice Williams, RN, ACNS-BC, CDE Professor of Nursing and Program Director Armstrong McDonald School of Nursing College of the Ozarks Point Lookout, Missouri

ix

The pace of scientific discovery in health and medicine continues to transform our understanding of physiology and disease. To be clinically relevant and useful to health care students and professionals, a text must synthesize a vast amount of detailed knowledge into overarching concepts that can be applied broadly. As in previous editions, the goal of the sixth edition of Pathophysiology is to include recent and relevant information on anatomy, biochemistry, cell physiology, genomics, and pathophysiology while not overwhelming the reader. Attention is given to major concepts relevant to clinical practice while still providing enough detail for deep understanding.

ORGANIZATION Pathophysiology uses a systems approach to content, beginning with a review of normal anatomy and physiology, followed by pathophysiology and application of concepts to specific disorders. The text is organized into 15 units, each of which includes a particular body system or group of interrelated body systems and the pertinent pathophysiologic concepts and disorders.

FEATURES An understanding of normal structure and function of the body is necessary for any detailed understanding of its abnormalities and pathophysiology. The first chapter in most units includes a fully illustrated review of normal physiology. Age-related concepts are highlighted in boxes titled Geriatric Considerations and Pediatric Considerations.

Each chapter opens with Key Questions, which are designed to alert the reader to important conceptual questions that will be discussed in the chapter. Although the chapters are meant to be read from beginning to end to develop an understanding of the material, the text also serves as a reference for looking up specific content. Chapter Outlines are included at the beginning of each chapter to help the reader locate specific content. Within every chapter, Key Points are identified at the end of every major discussion and are presented in short bulleted lists. These recurring summaries help readers to focus on the main points.

Nearly 900 illustrations elucidate both normal physiology and pathophysiologic changes. The entire book is in full color, with color

used generously in the illustrations to better explain pathophysiologic concepts.

A study of pathophysiology requires a new vocabulary, and many of these terms are defined in a comprehensive Glossary, which appears at the end of the text. Common prefixes and suffixes as well as root words are included in the back matter to help with basic understanding of the language of pathophysiology.

ANCILLARIES Student Learning Resources on Evolve The student section of the book’s website hosted on Evolve offers nearly 700 Student Review Questions in a variety of question formats, an Audio Glossary, Animations to help readers visualize pathophysiologic processes, Case Studies with questions, and Key Points Review. Visit the Evolve website at http://evolve.elsevier.com/Banasik/pathophysiology.

Study Guide Pathophysiology can be a daunting subject for students because of the large volume of factual material to be learned. The student Study Guide is designed to help students focus on important pathophysiologic concepts. Questions to check recall of normal anatomy and physiology are included for each chapter. A number of activities that help the student focus on similarities and differences between often-confused pathologic processes are included. More than 1500 self-assessment test questions with answers are included to help students check their understanding and build confidence for examinations. Case studies, with more than 250 questions including rationales for correct and incorrect answers, are used to help students begin to apply pathophysi- ologic concepts to clinical situations.

Instructor Learning Resources on Evolve The Instructor Learning Resources on Evolve provide a number of teaching aids for instructors who require the text for their students. The materials include a Test Bank presented in Exam View with approximately 1200 test items, a Teach for Nurses instructor manual detailing the resources available to instructors for their lesson planning, a PowerPoint lecture guide with more than 4000 slides with integrated case studies and audience response questions to facilitate classroom presentations, and an Image Collection of more than 900 color images from the text.

P R E F A C E

x

Revising this 6th edition of the text has been possible because of the tremendous dedication of authors, artists, reviewers, and editors. Sincere gratitude goes to all who helped with this and previous editions. In particular, grateful appreciation is extended to all of the contributing authors who have given exhaustively of their time over many editions over the decades. Thank you to the many thoughtful experts who gave their time to read and critique manuscripts and help ensure excellence in chapter content throughout the text.

Grateful recognition is made to the staff at Elsevier: Kellie White, Executive Content Strategist; Jennifer Wade, Content Development Specialist; Jeffrey Patterson, Publishing Service Manager; Carol O’Connell, Book Production Specialist; Renee Duenow, Book Designer; and Vikraman Palani, Multimedia Producer.

We would like to recognize those who provided a foundation for the revised text through their contributions to earlier editions: Arnold A. Asp, Donna Bailey, Barbara Bartz, Linda Belsky-Lohr, Tim Brown, Carolyn Spenee Cagle, Karen Carlson, Katherina P. Choka, Arnold Norman Cohen, Cynthia F. Corbett, Lorri Dawson, Leslie Evans, Patricia Garber, Jane Georges, Karen Groth, Christine M. Henshaw, Carolyn Hoover, Jo Annalee Irving, Marianne Genge Jagmin, Debby Kaaland, Naomi Lungstrom, Rick Madison, Anne Roe Mealey, David Mikkelsen, Carrie Miller, Linda Denise Oakley, Maryann Pranulis, Mark Puhlman, Edith Randall, Bridget Recker, Cleo Richard, Dawn Rondeau, Mary Sanguinetti-Baird, Billie Marie Severtsen, Jacqueline Siegel, Gary Smith, Sheila Smith, Martha Snider, Pam Springer, Angela Starkweather, Patti Stec, Julie Symes, Lorie Wild, and Debra Winston-Heath.

A C K N O W L E D G M E N T S

xixi

C O N T E N T S

UNIT I Pathophysiologic Processes

1 Introduction to Pathophysiology, 1 Lee-Ellen C. Copstead

Framework for Pathophysiology, 2 Etiology, 2 Pathogenesis, 2 Clinical Manifestations, 3 Treatment Implications, 3

Concepts of Normality in Health and Disease, 4 Statistical Normality, 4 Individual Factors Influencing Normality, 5

Patterns of Disease in Populations, 6 Concepts of Epidemiology, 6

2 Homeostasis, Allostasis, and Adaptive Responses to Stressors, 12 Debra A. Jansen and Roberta J. Emerson

Homeostasis and Allostasis, 12 Homeostasis, 12 Allostasis, 13

Stress as a Concept, 13 The General Adaptation Syndrome and

Allostasis, 14 Stressors, Gender and Developmental Influences,

and Risk Factors, 16 Neurohormonal Mediators of Stress and

Adaptation, 17 Catecholamines: Norepinephrine and

Epinephrine, 17 Adrenocortical Steroids: Cortisol and

Aldosterone, 18 Endorphins, Enkephalins, and Immune

Cytokines, 19 Sex Hormones: Estrogen, Testosterone, and

Dehydroepiandrosterone, 19 Growth Hormone, Prolactin, and

Oxytocin, 19 Adaptation, Coping, and Illness, 20

Adaptation, Coping, and Resilience, 20 Allostatic Overload and Illness, 21

UNIT II Cellular Function

3 Cell Structure and Function, 26 Jacquelyn L. Banasik and Brianne N. Banasik

Plasma Membrane, 27 Membrane Structure, 27 Lipid Bilayer, 27 Membrane Proteins, 29

Organization of Cellular Compartments, 30 Cytoskeleton, 30 Nucleus, 30 Endoplasmic Reticulum, 31 Golgi Apparatus, 32 Lysosomes and Peroxisomes, 33 Mitochondria, 34

Cellular Metabolism, 34 Glycolysis, 36 Citric Acid Cycle, 36 Oxidative Phosphorylation, 36

Functions of the Plasma Membrane, 39 Membrane Transport of Macromolecules, 39 Membrane Transport of Small Molecules, 40 Cellular Membrane Potentials, 45

Intercellular Communication and Growth, 48 Cell Signaling Strategies, 48 Cell Surface Receptor–Mediated Responses, 49 Intracellular Receptor–Mediated Responses, 53 Regulation of Cellular Growth and Proliferation, 54

4 Cell Injury, Aging, and Death, 59 Jacquelyn L. Banasik

Reversible Cell Injury, 59 Hydropic Swelling, 60 Intracellular Accumulations, 60

Cellular Adaptation, 63 Atrophy, 63 Hypertrophy, 63 Hyperplasia, 63 Metaplasia, 63 Dysplasia, 64

Irreversible Cell Injury, 64 Necrosis, 64 Apoptosis, 66

Etiology of Cellular Injury, 68 Ischemia and Hypoxic Injury, 68 Nutritional Injury, 70 Infectious and Immunologic Injury, 70 Chemical Injury, 72 Physical and Mechanical Injury, 72

Cellular Aging, 74 Cellular Basis of Aging, 74 Physiologic Changes of Aging, 75

Somatic Death, 75 5 Genome Structure, Regulation, and Tissue

Differentiation, 77 Jacquelyn L. Banasik

Structure and Function of DNA, 78 Structure of DNA, 78 DNA Replication, 79 Genetic Code, 80 Transcription, 81 Translation, 82

Regulation of the Genome, 84 Transcriptional Controls, 84

Differentiation of Tissues, 86 Cell Diversification and Cell Memory, 86 Mechanisms of Development, 86 Differentiated Tissues, 87

6 Genetic and Developmental Disorders, 94 Linda D. Ward

Principles of Inheritance, 95 DNA Mutation and Repair, 96

xii CoNTeNTs

GENETIC DISORDERS, 98 Chromosomal Abnormalities, 99

Aberrant Number of Chromosomes, 99 Abnormal Chromosome Structure, 100 Examples of Autosomal Chromosome

Disorders, 100 Examples of Sex Chromosome Disorders, 101

Mendelian Single-Gene Disorders, 102 Autosomal-Dominant Disorders, 103 Autosomal-Recessive Disorders, 104 Sex-Linked (X-Linked) Disorders, 106

Nonmendelian Single-Gene Disorders, 107 Anticipation, 109 Mitochondrial Gene Mutations, 109 Genomic Imprinting, 110

Polygenic and Multifactorial Disorders, 110 Environmentally Induced Congenital

Disorders, 111 Periods of Fetal Vulnerability, 111 Teratogenic Agents, 111 Other Disorders of Infancy, 113

Diagnosis, Counseling, and Gene Therapy, 113 Prenatal Diagnosis and Counseling, 113 Genetic Analysis and Therapy, 114 Recombinant DNA Technology, 114

7 Neoplasia, 117 Jacquelyn L. Banasik

Benign Versus Malignant Growth, 118 Characteristics of Benign and Malignant

Tumors, 118 Tumor Terminology, 118 The Malignant Phenotype, 118

Epidemiology and Cancer Risk Factors, 120 Tobacco Use, 120 Nutrition, 120

Genetic Mechanisms of Cancer, 123 Proto-Oncogenes, 124 Tumor Suppressor Genes, 127

Multistep Nature of Carcinogenesis, 129 Initiation, 129 Promotion, 131 Progression, 131

Metastasis, 132 Patterns of Spread, 132 Angiogenesis, 133 Grading and Staging of Tumors, 134

Effects of Cancer on the Body, 136 Cancer Therapy, 137

Surgery, 137 Radiation Therapy, 138 Drug Therapy, 138 Immunotherapy, 138 Gene and Molecular Therapy, 138 Stem Cell Transplantation, 139

UNIT III Defense

8 Infectious Processes, 141 Brent A. Banasik

Host–Microbe Relationship, 142 The Human Microbiome, 142

Host Characteristics, 142 Pathogen Characteristics, 144

Transmission of Infection, 147 Routes of Transmission, 148 Emerging Infectious Diseases, 148 Weapons of Bioterrorism, 149

Types of Pathogenic Organisms, 149 Bacteria, 149 Viruses, 150 Fungi, 151 Parasites, 152

9 Inflammation and Immunity, 158 Jacquelyn L. Banasik

COMPONENTS OF THE IMMUNE SYSTEM, 159

Epithelial Barriers, 159 Mononuclear Phagocyte System, 159 Lymphoid System, 160

Primary Lymphoid Organs, 160 Secondary Lymphoid Organs, 161

Leukocytes, 162 Neutrophils, 162 Eosinophils, 163 Basophils and Mast Cells, 164 Monocytes and Macrophages, 164 Dendritic Cells, 165 Lymphocytes, 165

Chemical Mediators of Immune Function, 167 Complement, 167 Kinins, 169 Clotting Factors, 169 Cytokines and Chemokines, 169

INNATE DEFENSES AND INFLAMMATION, 169 Inflammation, 171

Increased Vascular Permeability, 171 Emigration of Leukocytes, 172 Phagocytosis, 172 Chronic Inflammation, 174

Healing, 174 Inflammatory Exudates, 175 Systemic Manifestations of Inflammation, 175 SPECIFIC ADAPTIVE IMMUNITY, 176 Major Histocompatibility Complex, 176 Antigen Presentation by MHC, 176

MHC Class I Presentation, 177 MHC Class II Presentation, 177

Mechanisms of Cell-Mediated Immunity, 178 T Helper Cells (CD4+), 178 Cytotoxic T Cells (CD8+), 181

Mechanisms of Humoral Immunity, 181 Antigen Recognition by B Cells, 181

Antibody Structure, 183 Class Switching and Affinity Maturation, 185 Antibody Functions, 186

Passive and Active Immunity, 187 Passive Immunity, 187 Active Immunity, 187

INTEGRATED FUNCTION AND REGULATION OF THE IMMUNE SYSTEM, 189

Integrated Response to Microbial Antigen, 189 Integrated Response to Viral Antigen, 191 Regulation of Immune Function, 192

CoNTeNTs xiii

10 Alterations in Immune Function, 194 Faith Young Peterson

EXCESSIVE IMMUNE RESPONSES, 195 Autoimmunity, 195

Genetic Factors, 196 Environmental Triggers, 196 Pharmacotherapies, 197

Hypersensitivity, 198 Type I Hypersensitivity, 199 Type IIa Hypersensitivity, 201 Type IIb Hypersensitivity, 204 Type III Hypersensitivity, 204 Type IV Hypersensitivity, 207

DEFICIENT IMMUNE RESPONSES, 210 Primary Immunodeficiency Disorders, 210

B-Cell and T-Cell Combined Disorders, 210 T-Cell Disorders, 211 B-Cell Disorders, 212

Secondary Immunodeficiency Disorders, 212 11 Malignant Disorders of White Blood Cells, 215

Marie L. Kotter and Jacquelyn L. Banasik Classification of Hematologic Neoplasms, 215 Etiology of Myeloid and Lymphoid Neoplasms, 216 General Principles of Management, 217

Diagnosis of Hematologic Neoplasms, 217 Principles of Treatment, 218 Prevention and Management of Complications, 219

Myeloid Neoplasms, 221 Chronic Myeloid Leukemia, 221 Acute Myeloid Leukemia, 222

Lymphoid Neoplasms, 223 Chronic Lymphoid Leukemia, 223 Acute Lymphoblastic Leukemia/Lymphoma, 223 Hairy Cell Leukemia, 224 Plasma Cell Myeloma (Multiple Myeloma), 224 Hodgkin Disease, 227 B-Cell, T-Cell, and NK-Cell Lymphoma

(Non-Hodgkin), 229 12 HIV Disease and AIDS, 233

Faith Young Peterson Epidemiology, 234

History, 234 Types of HIV, 234 Transmission, 236 Prevention of Transmission, 238

Etiology, 239 HIV Structure, 239 HIV Binding and Infection, 239

Pathogenesis, 242 Effect of HIV on Immune Cells at the Cellular

Level, 242 Viral Production and Cell Death, 242 Progression of HIV Infection From Seroconversion

to AIDS, 244 CDC HIV Classification System, 245

Diagnostic Testing, 245 Monitoring the Progression of HIV, 246 Clinical Manifestations, 248

Systemic Manifestations, 248 Gastrointestinal Manifestations, 249 Pulmonary Manifestations, 249 Mucocutaneous Manifestations, 250

Gynecologic Manifestations, 251 Neurologic Manifestations, 252 Ocular Manifestations, 253 Cardiovascular Manifestations, 253 Manifestations in Other Systems, 253 Manifestations in Children, 254

Treatment, 254 Antiretroviral Therapy Recommendations, 254 Nucleoside Reverse Transcriptase Inhibitors, 255 Nucleotide Reverse Transcriptase Inhibitors, 255 Nonnucleoside Reverse Transcriptase

Inhibitors, 255 Protease Inhibitors, 257 Fusion Inhibitors, 257 CCR5 Inhibitors, 257 Integrase Strand Transfer Inhibitors, 257 Other Treatments and Vaccines, 257

UNIT IV Oxygen Transport, Blood Coagulation, Blood Flow, and Blood Pressure

13 Alterations in Oxygen Transport, 259 Susan G. Trevithick

Composition of Blood, 260 Organic and Inorganic Components, 261 Cellular Components, 261

Structure and Function of Red Blood Cells, 262 Hematopoiesis, 263 Hemoglobin Synthesis, 265 Nutritional Requirements for Erythropoiesis, 266 Energy and Maintenance of Erythrocytes, 267 Red Cell Production, 267 Red Cell Destruction, 268

Gas Transport and Acid–Base Balance, 268 Oxygen Transport, 268 Carbon Dioxide Transport, 270 Alterations in Oxygen Transport, 270

Anemia, 272 General Effects of Anemia, 272

Anemia Related to Decreased Red Cell Production, 277 Aplastic Anemia, 277 Anemia of Chronic Renal Failure, 277 Anemia Related to Vitamin B12 (Cobalamin)

or Folate Deficiency, 278 Iron Deficiency Anemia, 279

Anemia Related to Inherited Disorders of the Red Cell, 279 Thalassemia, 279 Sickle Cell Anemia, 281 Hereditary Spherocytosis, 282 Glucose-6-Phosphate Dehydrogenase

Deficiency, 282 Anemia Related to Extrinsic Red Cell Destruction or

Loss, 284 Hemolytic Disease of the Newborn, 284 Antibody-Mediated Drug Reactions, 284 Acute Blood Loss, 285 Other Extrinsic Abnormalities, 285

Transfusion Therapy, 286 Polycythemia, 286

xiv CoNTeNTs

Polycythemia Vera, 286 Secondary Polycythemia, 292 Relative Polycythemia, 293

14 Alterations in Hemostasis and Blood Coagulation, 298 Cheryl Rockwell

The Process of Hemostasis, 298 Stages of Hemostasis, 298 Platelets, 299 Blood Coagulation Factors, 299 Fibrin Clot, 299 Fibrinolysis, 301

Evaluation of Hemostasis and Coagulation, 301 Clinical Assessment, 301 Laboratory Tests, 304

Vascular and Platelet Disorders, 304 Vascular Disorders, 304 Platelet Disorders, 306

Coagulation Disorders, 308 15 Alterations in Blood Flow, 313

Teresa Grigsby Loftsgaarden Organization of the Circulatory and Lymphatic

Systems, 315 Vessel Structure, 315 Lymphatic Structure, 317

Principles of Flow, 317 Hemodynamics of the Circulatory System, 317

Control of Flow, 322 Control of Blood Flow, 322 Control of Lymphatic Flow, 323

General Mechanisms That Cause Altered Flow, 323 Blood Vessels: Obstructions, 323 Blood Vessels: Structural Alterations, 325 Lymphatic Vessels, 326

Alterations in Arterial Flow, 326 Arteriosclerosis/Atherosclerosis, 326 Thromboangiitis Obliterans (Buerger Disease), 330 Raynaud Syndrome, 330 Aneurysms, 330 Acute Arterial Occlusion, 331

Alterations in Venous Flow, 332 Valvular Incompetence, 332 Varicose Veins, 332 Chronic Venous Insufficiency, 333 Deep Vein Thrombosis, 333

Alterations in Lymphatic Flow, 333 Lymphedema, 333

16 Alterations in Blood Pressure, 337 Benjamin J. Miller

Arterial Blood Pressure, 337 Determinants of Systemic Blood Pressure, 337 Measurement of Blood Pressure, 338

Mechanisms of Blood Pressure Regulation, 341 Short-Term Regulation of Systemic Blood

Pressure, 341 Long-Term Regulation of Systemic Blood Pressure, 341 Normal Fluctuations in Systemic Blood Pressure, 343

Hypertension, 343 Definition and Classification, 343 Primary Hypertension, 344 Secondary Hypertension, 348 Hypertensive Emergencies and Urgency, 349

Low Blood Pressure, 350

UNIT V Cardiac Function

17 Cardiac Function, 354 Jacquelyn L. Banasik

Cardiovascular Anatomy, 355 Heart, 355 Circulatory System, 356

Cardiac Cycle, 358 Isovolumic Contraction, 359 Ventricular Ejection, 360 Isovolumic Relaxation, 360 Atrial Events, 360 Aortic and Pulmonary Artery Events, 360

Coronary Circulation, 360 Anatomy of the Coronary Vessels, 360 Regulation of Coronary Blood Flow, 361

Cardiac Myocytes, 363 Myocyte Structure, 363 Structure of the Contractile Apparatus, 363 Characteristics of Contractile Filaments, 365

Molecular Basis of Contraction, 366 Overview of Contraction, 366 Sliding Filament/Cross-Bridge Theory of Muscle

Contraction, 366 Role of Calcium in Muscle Contraction, 367 Energy of Muscle Relaxation, 367

Cardiac Energy Metabolism, 368 Oxygen Utilization, 368 Substrate Utilization, 369

Cardiac Electrophysiology, 369 Cardiac Resting Potential, 369 Cardiac Action Potential, 369 Rhythmicity of Myocardial Cells, 370 Specialized Conduction System of the Heart, 371 Autonomic Regulation of Rhythmicity, 372

Electrocardiography, 372 Determinants of Cardiac Output, 374

Determinants of Heart Rate, 374 Determinants of Stroke Volume, 375 Cardiac Workload, 376

Endocrine Function of the Heart, 376 Tests of Cardiac Function, 376

Electrocardiography, 376 Magnetic Resonance Imaging and Computed

Tomography, 378 Echocardiography, 378 Nuclear Cardiography, 379 Cardiac Catheterization/Coronary

Angiography, 379 18 Alterations in Cardiac Function, 382

Jacquelyn L. Banasik Coronary Heart Disease, 383

Etiology of Coronary Heart Disease, 383 Risk Factors and Mechanisms of Coronary

Atherosclerosis, 383 Pathophysiology of Ischemia, 385 Clinical Features and Management of Coronary

Syndromes, 388 Endocardial and Valvular Diseases, 394

Disorders of the Mitral Valve, 394 Disorders of the Aortic Valve, 397 Diseases of the Endocardium, 398

CoNTeNTs xv

Myocardial Diseases, 399 Myocarditis, 399 Cardiomyopathy, 400

Pericardial Diseases, 402 Pericardial Effusion, 402 Pericarditis, 402

Congenital Heart Diseases, 403 Embryologic Development, 403 Etiology and Incidence of Congenital Heart

Disease, 404 Pathophysiology of Congenital Heart

Disease, 405 Acyanotic Congenital Defects, 406 Cyanotic Congenital Defects, 408

19 Heart Failure and Dysrhythmias: Common Sequelae of Cardiac Diseases, 411 Benjamin J. Miller and Jacquelyn L. Banasik

Heart Failure, 412 Pathogenesis and Diagnosis, 412 Compensatory Mechanisms, Remodeling,

and Progression, 413 Clinical Manifestations, 417 Class and Stage of Heart Failure, 420 Treatment, 421

Cardiac Dysrhythmias, 421 Dysrhythmia Mechanisms, 421 Dysrhythmia Analysis, 423 Abnormal Rates of Sinus Rhythm, 424 Abnormal Site of Impulse Initiation, 425 Conduction Pathway Disturbances, 428 Treatment, 431

20 Shock, 434 Benjamin J. Miller

Pathogenesis of Shock, 434 Impaired Tissue Oxygenation, 435 Compensatory Mechanisms and Stages of

Shock, 437 Types of Shock, 439

Cardiogenic Shock, 439 Obstructive Shock, 441 Hypovolemic Shock, 442 Distributive Shock, 443

Assessment and Hemodynamic Monitoring, 447 Cardiac Output, 447 Arterial Oxygen Content, 447 Distribution of Blood Flow, 448 Hemodynamic Monitoring, 448

Complications of Shock, 449 Acute Respiratory Distress Syndrome, 449 Disseminated Intravascular Coagulation, 449 Acute Renal Failure, 449 Multiple Organ Dysfunction Syndrome, 449

UNIT VI Respiratory Function

21 Respiratory Function and Alterations in Gas Exchange, 451 Lorna L. Schumann

Functional Anatomy, 452 Development of the Pulmonary System, 452 Upper Airway Structures, 452

Lower Airway Structures, 453 Pulmonary Circulation, 457 Age-Related Variations, 457

Ventilation, 460 Lung Volumes and Capacities, 460 Dead Space, 460 Minute Ventilation, 460 Alveolar Ventilation/Oxygenation, 461 Mechanics of Breathing, 461 Airway Resistance, 461 Lung Compliance, 462 Distribution of Ventilation, 462 Neurologic Control of Ventilation, 462

Pulmonary Blood Flow, 465 Pulmonary Vasculature, 465 Distribution of Blood Flow, 465 Ventilation–Perfusion Ratios, 465 Hypoxic Vasoconstriction, 466

Diffusion and Transport of Respiratory Gases, 466 Barriers to Diffusion, 466 Oxygen Transport, 467 Carbon Dioxide Transport, 467

Alterations in Pulmonary Function, 468 Hypoventilation and Hyperventilation, 468 Hypoxemia and Hypoxia, 468 Acute Respiratory Failure, 469

Diagnostic Tests, 471 Pulmonary Function Testing, 471 Bronchial Provocation Tests, 472

Alterations in Pulmonary Vasculature, 472 Pulmonary Hypertension, 472 Pulmonary Venous Thromboembolism, 473

Pulmonary Malignancies, 475 Etiology, 475 Pathogenesis, 475 Clinical Manifestations, 476 Diagnosis, 476 Treatment, 476

22 Obstructive Pulmonary Disorders, 478 Benjamin J. Miller and Lorna L. Schumann

Obstruction From Conditions in the Wall of the Lumen, 479 Asthma, 479 Acute Bronchitis, 483 Chronic Bronchitis, 485

Obstruction Related to Loss of Lung Parenchyma, 488 Emphysema, 488

Obstruction of the Airway Lumen, 491 Bronchiectasis, 491 Bronchiolitis, 493 Cystic Fibrosis, 494 Acute Tracheobronchial Obstruction, 495 Epiglottitis, 496 Croup Syndrome, 496

23 Restrictive Pulmonary Disorders, 499 Lorna L. Schumann and Benjamin J. Miller

Lung Parenchyma Disorders, 500 Fibrotic Interstitial Lung Diseases, 500

Atelectatic Disorders, 504 Pleural Space Disorders, 508

xvi CoNTeNTs

Neuromuscular, Chest Wall, and Obesity Disorders, 511 Neuromuscular Disorders, 511 Chest Wall Deformities, 511 Disorders of Obesity, 513

Infection or Inflammation of the Lung, 514

UNIT VII Fluid, Electrolyte, and Acid-Base Homeostasis

24 Fluid and Electrolyte Homeostasis and Imbalances, 521 Linda Felver

Body Fluid Homeostasis, 522 Fluid Intake and Absorption, 522 Fluid Distribution, 523 Fluid Excretion, 524 Fluid Loss Through Abnormal Routes, 524

Fluid Imbalances, 525 Extracellular Fluid Volume, 525 Body Fluid Concentration, 526 Both Volume and Concentration, 528 Interstitial Fluid Volume, 528

Principles of Electrolyte Homeostasis, 529 Electrolyte Intake and Absorption, 529 Electrolyte Distribution, 531 Electrolyte Excretion, 531 Electrolyte Loss Through Abnormal Routes, 531

Electrolyte Imbalances, 531 Plasma Potassium, 531 Plasma Calcium, 533 Plasma Magnesium, 534 Plasma Phosphate, 535

25 Acid–Base Homeostasis and Imbalances, 541 Linda Felver

Acid–Base Homeostasis, 541 Buffers, 542 Respiratory Contribution, 542 Renal Contribution, 543

Acid–Base Imbalances, 545 Mixed Acid–Base Imbalances, 549

UNIT VIII Renal and Bladder Function

26 Renal Function, 551 Jacquelyn L. Banasik

Renal Anatomy, 552 Renal Parenchyma, 552 Renal Lymphatics and Innervation, 552 Renal Blood Supply, 553

Overview of Nephron Structure and Function, 554 Glomerulus, 555 Proximal Convoluted Tubule, 557 Loop of Henle, 558 Distal Convoluted Tubule, 559 Collecting Duct, 559

Regulation of Glomerular Filtration, 560 Physics of Filtration, 560 Factors Affecting Filtration Pressure, 562 Tubuloglomerular Feedback, 563

Effects of Glucose and Amino Acids, 563 Role of Mesangial Cells, 564

Transport Across Renal Tubules, 565 Reabsorption of Glucose, 565 Regulation of Acid–Base Balance, 565 Secretion of Potassium, 566

Regulation of Blood Volume and Osmolality, 567 Antidiuretic Hormone, 567 Aldosterone, Angiotensin II, Natriuretic

Peptides, Urodilatin, Uroguanylin, and Guanylin, 568

Diuretic Agents, 569 Endocrine Functions, 570

Erythropoietin, 570 Vitamin D, 570

Age-Related Changes in Renal Function, 570 Infant, 570 Adult and Elderly, 570

Tests of Renal Structure and Function, 570 Urine and Blood Studies, 570 Diagnostic Tests, 572

27 Intrarenal Disorders, 575 Jacquelyn L. Banasik and Roberta J. Emerson

Common Manifestations of Kidney Disease, 575 Pain, 575 Abnormal Urinalysis Findings, 576 Other Diagnostic Tests, 576

Congenital Abnormalities, 577 Renal Agenesis and Hypoplasia, 577 Cystic Kidney Diseases, 578

Neoplasms, 579 Infection, 581 Obstruction, 583 Glomerular Disorders (Glomerulopathies), 586

Glomerulonephritis, 587 Nephrotic Syndrome, 589

28 Acute Kidney Injury and Chronic Kidney Disease, 593 Cheryl Rockwell and Robin Y. Beeman

Acute Kidney Injury, 593 Etiology and Pathophysiology, 594 Clinical Presentation of Acute Kidney Injury, 596

Chronic Kidney Disease, 601 Risk Factors, 601 Pathophysiology of Progression of Chronic

Kidney Disease, 602 Stages of Chronic Kidney Disease, 602 Complications of Chronic Kidney Disease, 602

Clinical Management, 604 29 Disorders of the Lower Urinary Tract, 609

Cheryl L. Brandt Lower Urinary Tract, 609

Functional Anatomy, 609 Physiology of Micturition, 610 Diagnostic Tests, 611

Lower Urinary Tract Symptoms and Syndromes, 611

Neurogenic Bladder, 614 Congenital Disorders, 615 Neoplasms, 617 Inflammation and Infection, 619 Obstruction, 622

Lower Urinary Tract Calculi, 622

CoNTeNTs xvii

UNIT IX Genital and Reproductive Function

30 Male Genital and Reproductive Function, 626 Marvin Van Every

Anatomy, 626 Upper Genitourinary Tract, 626 Lower Genitourinary Tract, 627 Auxiliary Genital Glands, 628 External Genitalia, 629

Embryology, 632 Nephric System, 632 Vesicourethral Unit, 633 Gonads, 633 Genital Duct System, 633 External Genitalia, 633

Male Reproductive Physiology, 633 Hypothalamic-Pituitary-Testicular Axis, 633 Spermatogenesis, 637 Anatomy of Spermatozoa, 637 Transport of Spermatozoa, 637

31 Alterations in Male Genital and Reproductive Function, 641 Marvin Van Every

Disorders of the Penis and Male Urethra, 641 Congenital Anomalies, 641 Acquired Disorders, 643 Infectious Disorders, 645 Neoplastic Disorders, 647

Disorders of the Scrotum and Testes, 647 Congenital Disorders, 647 Acquired Disorders, 648 Infectious Disorders, 650 Neoplastic Disorders, 650

Disorders of the Prostate, 651 32 Female Genital and Reproductive Function, 656

Rosemary A. Jadack Reproductive Structures, 656

Organization of the Female Reproductive Organs, 656

Menstrual Cycle, 659 Breast, 662

Structure of the Breast, 662 Breast Development, 662 Lactation, 663

Pregnancy, 663 Early Human Development, 663 Implantation, 663 Fetal Membranes and Placenta, 663 Development of the Human Embryo and Fetus, 664 Parturition, 665 Response of the Mother’s Body to Pregnancy, 667

Menopause, 668 33 Alterations in Female Genital and Reproductive

Function, 671 Rosemary A. Jadack

Menstrual Disorders, 672 Alterations in Uterine Position and Pelvic

Support, 674 Inflammation and Infection of the Female

Reproductive Tract, 676 Benign Growths and Aberrant Tissue of the Female

Reproductive Tract, 678

Cancer of the Female Genital Structures, 679 Disorders of Pregnancy, 681 Disorders of the Breast, 682

Reactive-Inflammatory Breast Disorders, 682 Benign Breast Disorders, 683 Malignant Disorder of the Breast, 684

34 Sexually Transmitted Infections, 689 Rosemary A. Jadack

Urethritis, Cervicitis, Salpingitis, and Pelvic Inflammatory Disease, 690

Diseases With Systemic Involvement, 691 Diseases With Localized Lesions, 694

Ulcerative Lesions, 694 Nonulcerative Lesions, 694

Enteric Infections, 695

UNIT X Gastrointestinal Function

35 Gastrointestinal Function, 697 Jeffrey S. Sartin

Structure and Organization of the Gastrointestinal Tract, 698 Embryology, 698 Functional Anatomy, 699

Gastrointestinal Motility, 704 Characteristics of the Intestinal Wall, 704 Neural Control, 704 Hormonal Control, 706 Movement in the Gastrointestinal Tract, 706 Movement of Nutrients, 707

Secretory Function, 712 Secretion of Gastrointestinal Juices, 712 Gastrointestinal Hormones, 712

Digestion and Absorption, 712 Digestion of Carbohydrates, 713 Digestion of Lipids, 713 Digestion of Proteins, 714 Absorption, 715

Gastrointestinal Function Across the Life Span, 717 Maturation, 717 Age-Related Changes, 717

36 Gastrointestinal Disorders, 720 Jeffrey S. Sartin

Manifestations of Gastrointestinal Tract Disorders, 721 Dysphagia, 721 Esophageal Pain, 721 Abdominal Pain, 721 Vomiting, 723 Intestinal Gas, 723 Alterations in Bowel Patterns, 723

DISORDERS OF THE MOUTH AND ESOPHAGUS, 724

Oral Infections, 724 Esophageal Disorders, 724 ALTERATIONS IN THE INTEGRITY OF

THE GASTROINTESTINAL TRACT WALL, 726

Inflammation of the Stomach and Intestines, 726

xviii CoNTeNTs

Inflammatory Bowel Disease, 728 Enterocolitis, 731 ALTERATIONS IN MOTILITY OF THE

GASTROINTESTINAL TRACT, 733 Motility Disorders, 733 Disorders of Malabsorption, 735 Mucosal Disorders, 735 Malabsorption Disorders After Surgical

Intervention, 735 NEOPLASMS OF THE GASTROINTESTINAL

TRACT, 737 Esophageal, Gastric, and Small Intestinal

Cancers, 737 Colonic Polyps and Colon Cancer, 738 Psychosocial Aspects of Gastrointestinal

Disorders, 739 Stress of Lifestyle Changes, 739

37 Alterations in Function of the Gallbladder and Exocrine Pancreas, 742 Jeffrey S. Sartin

Structure and Function of the Pancreaticobiliary System, 742

Embryology of the Pancreaticobiliary System, 743

Physiology of Bile, 743 Functional Anatomy of the Pancreas, 744 Disorders of the Gallbladder, 744

Pathophysiology of Cholesterol Gallstone Formation, 744

Cholelithiasis and Cholecystitis, 745 Disorders of the Pancreas, 748

Pancreatitis, 748 38 Liver Diseases, 754

Jeffrey S. Sartin Structure and Function of the Liver, 755 General Manifestations of Liver Disease, 755

Hepatocellular Failure, 755 Portal Hypertension, 759 Portal Systemic Encephalopathy, 763 Complications of Advanced Liver

Disease, 764 Disorders of the Liver, 767

Hepatitis, 767 Chronic Hepatitis, 772

Cirrhosis, 773 Alcoholic Liver Disease, 773

Toxic Liver Disorders, 774 Metal Storage Diseases, 774 Toxic Metabolic Agents, 775

Other Structural Liver Conditions, 775 Transplantation, 776

Evaluation of the Transplantation Patient, 777

Posttransplantation Management, 777 Age-Related Liver Disorders, 778

Liver Diseases and Pediatric Considerations, 778 Abnormal Bilirubin Metabolism in the Neonatal

Period, 778 Infectious and Acquired Hepatitides in

Children, 778 Congenital Liver Disease, 779

Liver Diseases and Geriatric Considerations, 780

UNIT XI Endocrine Function, Metabolism, and Nutrition

39 Endocrine Physiology and Mechanisms of Hypothalamic-Pituitary Regulation, 783 Jacquelyn L. Banasik

Hormone Structure and Action, 784 Chemical Structure of Hormone Classes, 784 Mechanisms of Hormone Action, 784

Hormone Regulation, 786 Hormone Synthesis, Secretion, and

Metabolism, 786 Regulation of Receptor Responses, 787

Hypothalamic-Pituitary Endocrine System, 788 Hormones of the Posterior Pituitary Gland, 788 Hormones of the Hypothalamus and Anterior

Pituitary Gland, 790 Thyroid Hormones, 793

Thyroid Hormone Synthesis and Secretion, 793 Thyroid Action on Target Cells, 793

Steroid Hormones, 794 Steroid Hormone Synthesis and Secretion, 794 Steroid Action on Target Cells, 795

Categories of Endocrine Disease, 797 Hyposecretion, 797 Hypersecretion, 797 Hyporesponsiveness, 797

40 Disorders of Endocrine Function, 799 Jacquelyn L. Banasik

Basic Concepts of Endocrine Disorders, 799 Etiology of Endocrine Disorders, 799 Classification of Endocrine Disorders, 800

Growth Hormone Disorders, 801 Thyroid Hormone Disorders, 803 Adrenocortical Hormone Disorders, 806 Adrenal Medulla Disorder, 810 Parathyroid Gland Disorders, 811

Regulation and Actions of Parathyroid Hormone, 811

Antidiuretic Hormone Disorders, 812 41 Diabetes Mellitus, 815

Benjamin J. Miller Regulation of Glucose Metabolism, 816

Hormonal Regulation, 816 Neural Regulation, 817 Exercise, 818 Stress, 818

Glucose Intolerance Disorders, 820 Classification of Glucose Intolerance

Disorders, 820 Prediabetes, 820 Diabetes Mellitus, 821 Screening for Diabetes, 824

Clinical Manifestations and Complications, 825 Acute Hyperglycemia, 825 Diabetic Ketoacidosis, 825 Nonketotic Hyperglycemic Hyperosmolar

Syndrome, 826 Chronic Hyperglycemia, 826 Vascular Complications, 826 Neuropathic Complications, 827 Complications in Pregnancy, 827

CoNTeNTs xix

Treatment and Education, 827 Nutrition, 828 Obesity and Eating Disorders, 828 Exercise, 829 Pharmacologic Agents, 829 Stress Management, 831 Assessment of Efficacy, 831

Pediatric Considerations, 833 Goals of Therapy, 834 Acute Complications, 834 Chronic Complications, 834 Treatment, 834

Geriatric Considerations, 834 Goals of Therapy, 835 Acute Complications, 835 Chronic Complications, 835 Treatment, 835

42 Nutritional and Metabolic Disorders, 838 Brent A. Banasik

Metabolic Processes, 838 Anabolism and Catabolism, 839 Metabolic Rate, 839

Nutrient Metabolism, 839 Carbohydrates, 839 Lipids, 840 Proteins, 841

Regulation of Appetite and Nutrient Metabolism, 841 Role of Genetics, Epigenetics, and

Environment, 841 Hormonal Regulation of Nutrient Intake and

Appetite, 842 Hormonal Regulation of Nutrient Storage,

Distribution, and Metabolism, 843 Obesity and Metabolic Syndrome, 844

Obesity, 844 Metabolic Syndrome, 844

Metabolic Responses to Starvation and Physiologic Stress, 844 Starvation and Protein-Energy Malnutrition, 845 Physiologic Stress, 845

Nutritional Considerations for Aging and Altered Health States, 846 Aging, 846 Infection, Sepsis, and Fever, 846 Surgery, 848 Trauma, 848 Burns, 848 Cancer, 848 Immobility, 848

UNIT XII Neural Function

43 Structure and Function of the Nervous System, 850 Jacquelyn L. Banasik

STRUCTURAL ORGANIZATION, 851 Central Nervous System, 851

Support and Protection of the Central Nervous System, 851

The Brain, 853 The Spinal Cord, 861

Peripheral Nervous System, 863 Cranial Nerves, 863 Spinal Nerves, 864

Autonomic Nervous System, 867 NEURONAL STRUCTURE AND FUNCTION, 868 Neurons and Supportive Cells, 868

Neurons, 868 Glia, 868

Neuronal Communication, 872 Membrane Potentials, 872 Synaptic Transmission, 874 Neurotransmitters, 875 Neuronal Circuits, 880

Neural Development, Aging, and Injury, 880 Development, 880 Aging, 881 Injury, 881

SENSORY FUNCTION, 882 Sensory Receptors, 882 Sensory Pathways, 883 Somatosensory Cortex, 883 MOTOR FUNCTION, 883 Motor Neurons, 884 Spinal Reflexes, 884 Central Control of Motor Function, 885 CONSCIOUSNESS, MEMORY, AND SLEEP, 886 Consciousness and Memory, 886 Sleep, 888

44 Acute Disorders of Brain Function, 891 Joni D. Marsh and Jacquelyn L. Banasik

Mechanisms of Brain Injury, 892 Ischemia and Hypoxia, 892 Increased Intracranial Pressure, 895

Manifestations of Brain Injury, 900 Level of Consciousness, 900 Glasgow Coma Scale, 900 Cranial Nerve Reflexes, 901

TRAUMATIC BRAIN INJURY, 902 Epidemiology, 902 Types of Traumatic Brain Injury, 903 Primary Injury, 903

Intracranial Hematomas, 903 Secondary Injury, 905 Treatment, 905 CEREBROVASCULAR DISEASE AND

STROKE, 905 Epidemiology, 906 Ischemic Stroke, 906 Hemorrhagic Stroke, 906 Treatment, 906 Stroke Sequelae, 908

Motor and Sensory Deficits, 908 Language Deficits, 908 Cognitive Deficits, 908

CREBRAL ANEURYSM AND ARTERIOVENOUS MALFORMATION, 909

Cerebral Aneurysm, 909 Etiology, 909 Pathogenesis and Manifestations, 910 Treatment, 910

Arteriovenous Malformation, 911 Etiology, 911

xx CoNTeNTs

Pathogenesis and Manifestations, 911 Treatment, 911

CENTRAL NERVOUS SYSTEM INFECTIONS, 911 Meningitis, 911

Etiology, 911 Pathogenesis and Clinical Manifestations, 911 Treatment, 911

Encephalitis, 912 Etiology, 912 Pathogenesis and Manifestations, 912 Treatment, 912

Brain Abscess, 912 Etiology, 912 Pathogenesis and Manifestations, 912 Treatment, 913

45 Chronic Disorders of Neurologic Function, 915 Joni D. Marsh

Brain and Cerebellar Disorders, 916 Seizure Disorder, 916 Dementia, 918 Parkinson Disease, 920 Cerebral Palsy, 922 Hydrocephalus, 923 Cerebellar Disorders, 924

Spinal Cord and Peripheral Nerve Disorders, 925 Multiple Sclerosis, 925 Spina Bifida, 927 Amyotrophic Lateral Sclerosis, 928 Spinal Cord Injury, 928 Guillain-Barré Syndrome, 931 Bell Palsy, 932

46 Alterations in Special Sensory Function, 936 Joni D. Marsh

HEARING AND BALANCE, 937 Structure and Function of the Ear, 937

External Ear, 937 Middle Ear, 937 Inner Ear, 937 Balance, 938

General Manifestations of Hearing Impairment, 938 Hearing Impairment Disorders, 939

Conductive Hearing Impairment, 939 Sensorineural Hearing Impairment, 939

Otitis Media, 941 Interventions for Individuals With Hearing

Impairment, 942 VISION, 942 Structure of the Eye, 942 Visual Pathways, 943 General Manifestations of Visual Impairment, 944 Disorders of the Eye, 944

Errors of Refraction, 944 Age-Related Disorders, 945 Retinopathy, 947 Glaucoma, 948 Visual Field Deficits, 950

Interventions for Individuals With Vision Impairment, 950

SMELL AND TASTE, 952 47 Pain, 955

Joni D. Marsh Physiology of Pain, 955

Transduction, 956 Transmission, 956 Perception, 958 Modulation, 958

TYPES OF PAIN, 960 Acute Pain, 961

Headache, 962 Chronic Pain, 962

Fibromyalgia Syndrome, 963 Cancer-Related Pain, 964 Neuropathic Pain, 964

Trigeminal Neuralgia, 965 Diabetic Neuropathy, 965 Postherpetic Neuralgia, 966

Ischemic Pain, 966 Referred Pain, 966 Physiologic Responses to Pain, 967 Pain in the Young and the Elderly, 967 TREATMENT MODALITIES, 967 Pharmacologic and Nonpharmacologic Pain

Management, 967 Interrupting Peripheral Transmission of Pain, 968 Modulating Pain Transmission at the Spinal

Cord, 968 Altering the Perception and Integration of

Pain, 968

UNIT XIII Neuropsychological Function

48 Neurobiology of Psychotic Illnesses, 971 Ann Futterman Collier and Samantha Cody Russell

Schizophrenia, 972 Etiology and Neurobiology, 972 Clinical Manifestations, 976 Pharmacologic Treatment, 976 Nonpharmacologic Treatment, 977

Major Depressive and Persistent Depressive Disorders, 978 Etiology and Neurobiology, 979 Clinical Manifestations, 980 Pharmacologic Treatment, 981 Nonpharmacologic Treatment, 981

Bipolar Disorder, 982 Etiology and Neurobiology, 982 Clinical Manifestations, 983 Pharmacologic Treatment, 983 Nonpharmacologic Treatment, 984

Population Considerations, 984 Women and Mental Illness, 984 Cultural Considerations, 984 Geriatric Considerations, 984

49 Neurobiology of Nonpsychotic Illnesses, 989 Ann Futterman Collier and Samantha Cody Russell

Anxiety Disorders, 989 Panic Disorder, 990 Generalized Anxiety Disorder, 991 Obsessive-Compulsive Disorder, 992 Posttraumatic Stress Disorder, 994

Neurodevelopmental Disorders, 995 Attention-Deficit/Hyperactivity Disorder, 996 Autism Spectrum Disorder, 997

CoNTeNTs xxi

UNIT XIV Musculoskeletal Support and Movement

50 Structure and Function of the Musculoskeletal System, 1001 Carol L. Danning

Structure and Function of Bone, 1002 Composition, 1002 Functional Properties, 1003 Response to Injury, Stress, and Aging, 1004

Structure and Function of Joints, 1006 Synarthroses, 1007 Diarthroses, 1007

Structure and Function of Articular Cartilage, 1011 Composition, 1011 Functional Properties, 1011 Response to Injury, Stress, and Aging, 1012

Structure and Function of Tendons and Ligaments, 1012 Composition, 1012 Functional Properties, 1013 Response to Injury, Stress, and Aging, 1013

Structure and Function of Skeletal Muscle, 1013 Composition, 1014

Mechanics of Muscle Contraction, 1015 Sliding Filament Theory, 1015 Role of Calcium, 1015 Electromechanical Coupling, 1015 Types of Muscle Contraction, 1016 Mechanical Principles, 1017 Response to Movement and Exercise, 1017

51 Alterations in Musculoskeletal Function: Trauma, Infection, and Disease, 1020 Carol L. Danning

SOFT TISSUE INJURIES, 1021 Inert Soft Tissue Injuries, 1021

Ligament Injuries, 1021 Joint Capsule Injuries, 1022 Internal Joint Derangement, 1023 Injuries to Fasciae and Bursae, 1023 Injuries to Nerves, Nerve Roots, or Dura

Mater, 1023 Contractile Soft Tissue Injuries, 1023

Injury to Tendons, 1023 Muscle and Tendon Strains, 1024 Blunt Trauma, 1024 Compartment Syndrome, 1024 Soft Tissue Healing After Trauma, 1024

BONE INJURIES AND INFECTIONS, 1026 Bone and Joint Trauma, 1026

Types of Bone, 1026 Fracture, 1026 Dislocations and Subluxations, 1030

Infections of the Bone, 1031 Osteomyelitis, 1031 Tuberculosis, 1032

ALTERATIONS IN BONE STRUCTURE AND MASS, 1032

Bone Structure Disorders, 1032 Scoliosis, 1032

Metabolic Bone Diseases, 1033

Osteoporosis, 1033 Rickets and Osteomalacia, 1035 Paget Disease, 1035

Bone Tumors, 1036 Benign Tumors, 1036 Malignant Bone Tumors, 1037

DISEASES OF SKELETAL MUSCLE, 1038 Idiopathic Inflammatory Myopathy, 1038

Polymyositis and Dermatomyositis, 1038 Muscular Dystrophy, 1039

Duchenne Muscular Dystrophy, 1039 Becker Muscular Dystrophy, 1039 Facioscapulohumeral Muscular Dystrophy, 1039 Myotonic Dystrophies, 1039

OTHER DISORDERS OF MUSCLE, 1039 Myasthenia Gravis, 1039

Treatment, 1039 Chronic Muscle Pain, 1040

Fibromyalgia Syndrome, 1040 52 Alterations in Musculoskeletal Function: Rheumatic

Disorders, 1042 Carol L. Danning

Local Disorders of Joint Function, 1042 Osteoarthritis, 1042 Infectious Arthritis, 1045 Lyme Disease, 1045

Systemic Disorders of Joint Function, 1046 Immune-Mediated Disorders, 1046 Postinfectious Systemic Disorders, 1052

Joint Dysfunction Secondary to Other Diseases, 1053 Psoriatic Arthritis, 1053 Enteropathic Arthritis, 1053 Neuropathic Osteoarthropathy, 1054 Hemophilic Arthropathy, 1054 Gout, 1054 Adult-Onset Still Disease, 1055

Pediatric Joint Disorders, 1056 Nonarticular Rheumatism, 1056 Hypermobility of Joints, 1056 Juvenile Idiopathic Arthritis, 1056

UNIT XV Integumentary System

53 Alterations in the Integumentary System, 1058 Lee-Ellen C. Copstead, Ruth E. Diestelmeier, and Michael R. Diestelmeier

Age-Related Changes, 1059 Epidermis, 1060 Dermis and Subcutaneous Tissue, 1060 Appendages, 1061

Evaluation of the Integumentary System, 1061 Primary and Secondary Lesions, 1061 Lesion Descriptors, 1062

Selected Skin Disorders, 1063 Infectious Processes, 1064

Viral Infections, 1064 Fungal Infections, 1065 Bacterial Infections, 1067

Inflammatory Conditions, 1069 Allergic Skin Responses, 1072 Parasitic Infestations, 1075

xxii CoNTeNTs

Other Disorders of the Dermis, 1076 Scleroderma, 1076 Sunburn and Photosensitivity, 1077 Ulcers, 1078 Altered Cell Growth: Epidermal Proliferation, 1078 Pigmentation Alterations, 1080

Special Characteristics of Dark Skin, 1081 Integumentary Manifestations of Systemic

Disease, 1083 Skin, 1083 Hair, 1084 Nails, 1084

Treatment Implications, 1086 Topical Treatment, 1086 Intralesional Injection, 1086 Selection of a Delivery System, 1087 Corticosteroids, 1087

Developmental Considerations, 1087 Infancy, 1087 Childhood Skin Disorders, 1088 Adolescence and Young Adulthood, 1090 Geriatric Considerations, 1090

54 Burn Injuries, 1093 Sarah Ogle and Nirav Patel

Thermal Injury, 1094 Etiology, Incidence, and Mortality, 1094

Risk Factors, 1094 Integument Effects, 1094 Depth Classification, 1096 Extent of Injury, 1097 Severity Classification, 1097 Acute Management, 1097 Assessment, 1099 Burn Shock and Acute Resuscitation, 1099 Organ Dysfunction, 1101 Metabolic Changes, 1102 Cellular Changes, 1102 Immune Response, 1103 Elements of Burn Injury Survival, 1103 Rehabilitation Phase, 1106

Electrical Injury, 1107 Incidence and Mortality, 1107 Pathophysiology, 1107 Management and Complications, 1108

Chemical Injury, 1109 Management and Complications, 1109 Common Agents and Treatment, 1109

Special Populations, 1110 Introduction, 1110

Glossary, 1114 Index, 1143

1

Introduction to Pathophysiology Lee-Ellen C. Copstead

UNIT I Pathophysiologic Processes

1

K E Y Q U E S T I O N S • What is pathophysiology? • How are etiology and pathogenesis used to predict clinical

manifestations and response to therapy? • How are normal and abnormal physiologic parameters defined?

C H A P T E R O U T L I N E Framework for Pathophysiology, 2

Etiology, 2

Pathogenesis, 2

Clinical Manifestations, 3

Stages and Clinical Course, 3

Treatment Implications, 3

Concepts of Normality in Health and Disease, 4 Statistical Normality, 4

Reliability, Validity, and Predictive Value, 5 Individual Factors Influencing Normality, 5

Cultural Considerations, 5

• What general factors affect the expression of disease in a particular person?

• What kinds of information about disease can be gained through understanding concepts of epidemiology?

Pathophysiology derives from the intersection of two older, related disciplines: pathology (from pathos, suffering) and physiology (from physis, nature). Pathology is the study and diagnosis of disease through examination of organs, tissues, cells, and bodily fluids. Physiology is the study of the mechanical, physical, and biochemical functions of living organisms. Together, as pathophysiology, the term refers to the study of abnormalities in physiologic functioning of living beings.

Pathophysiology seeks to reveal physiologic responses of an organism to disruptions in its internal or external environment. Because humans exhibit considerable diversity, healthy structure and function are not precisely the same in any two individuals. However, discovering the common and expected responses to abnormalities in physiologic func- tioning is useful, and it allows a general prediction of clinical progression, identification of possible causes, and selection of interventions that are

most likely to be helpful. Thus pathophysiology is studied in terms of common, or “classic,” presentations of disorders.

Historically, descriptions of diseases were based on observations of those individuals who attracted medical attention because they exhibited abnormal signs or complained of symptoms. Over time, cases with similar presentations were noted and treatments that had been successful before were used again. In some cases, similarities among individuals pointed to possible common causes. With the advent of more sophis- ticated measurements of physiologic and biochemical function, such as blood pressure measurements, blood chemistry values, x-ray images, and DNA analysis, the wide variability in the expression of diseases and disorders in the population became apparent, as did the opportunity to discover diseases at earlier stages, before they were clinically obvious. Screening programs that evaluated large segments of the population

Age Differences, 6 Gender Differences, 6 Situational Differences, 6 Time Variations, 6

Patterns of Disease in Populations, 6 Concepts of Epidemiology, 6

Endemic, Pandemic, and Epidemic Diseases, 7 Aggregate Factors, 7 Levels of Prevention, 9

http://evolve.elsevier.com/Banasik/pathophysiology/ • Review Questions and Answers • Glossary (with audio pronunciations for selected terms) • Animations

• Case Studies • Key Points Review

2 UNIT I Pathophysiologic Processes

present, it is termed a risk factor. The identification of risk factors is important for disease prevention, and various levels of prevention provide a focus for the epidemiology section at the end of this chapter.

Some diseases are closely linked with etiologic factors, such that they are said to be the causative agents in the disease. For example, microbial pathogens are considered to be causative agents for infectious diseases: Ebola virus disease—a rare and deadly disease—is caused by infection with a virus of the family Filoviridae, genus Ebolavirus (Fig. 1.1); human immunodeficiency virus causes HIV disease, and Myco- bacterium tuberculosis causes pulmonary tuberculosis. These diseases do not occur unless the pathogen is present in the body; however, this does not mean that the infection will have the same consequences in each case, because many host factors affect the clinical course.

Even when the link between disease and etiologic agent is strong, only a portion of the population exposed to the factor may develop the disease. For example, in persons who consume large quantities of alcohol and develop liver cirrhosis, it is the alcohol consumption that is considered to be the cause, yet only a portion of persons who drink heavily will develop cirrhosis. Thus categorizing the probable etiologies for diseases is a long, difficult research process and, not surprisingly, the exact causes of most disorders remain incompletely understood. Several classification schemes have been proposed to categorize diseases according to etiology. Box 1.1 summarizes an example of an etiologic classification system. No classification system is truly comprehensive, and some diseases fall into multiple categories. Some diseases may receive different designations in the future, as further research reveals new data.

Pathogenesis Pathogenesis refers to the development or evolution of a disease, from the initial stimulus to the ultimate expression of the manifestations of the disease. The sequence of physiologic events that occurs in response to an etiologic agent is a dynamic interplay of changes in cell, tissue, organ, and systemic function. As the ways in which intricate intercellular communication networks control physiologic function are discovered,

revealed the complexity and diversity of disease expression, even in persons with the same genetic defect. Thus although the study of pathophysiology is necessarily a study of the usual and expected responses of the body to a given disruption, individuals often vary significantly from a classic presentation, making the diagnostic process complex and challenging.

Advances in genomic and epigenomic characterization, innovative technologies, and revolutionary approaches to the analysis of genetic variation and function have made studies and treatments possible that were not even imaginable just a few years ago. As a result, definitions of the living world have been virtually transformed and permeate every branch of biological science. Benefits of this new biology include a deeper understanding of evolution, greater insights into immune mechanisms, and advances against cancer and AIDS.

Genetic manipulation also raises sensitive and complex ethical and moral questions that did not exist half a century ago. Scientists are able to experiment with genetic manifestations and their mechanisms of action, dramatically altering medical practice, especially the management of inherited diseases. New capabilities have led to experimental treatments such as gene therapy–molecular surgery powerful enough to cure and alter the next generation. The study of pathophysiology assumes even greater significance as genetic research shows fresh insights and hopeful new treatments for human diseases.

Pathophysiology examines disturbances of normal mechanical, physical, and biochemical functions, either caused by a disease or resulting from a disease or abnormal syndrome or condition. For example, the study of a toxin released by a bacterium has evolved from the science of infectious diseases, as well as the harmful effects of that toxin on the body, with one possible result being sepsis. Another example is the study of the chemical changes that take place in body tissue as the result of inflammation.

Although individual study of specific diseases undertaken in medical pathology textbooks helps students identify subtle differences between similar diseases, the study of pathophysiology is dynamic and conceptual, seeking to explain processes and relationships common to a number of pathologies. For example, the pathophysiology of inflammation, hypotension, fluid volume deficit, hypoxia, and ischemia is important to the understanding of a large number of different pathologies, but each separate process is not necessarily a specific disease.

Pathophysiology includes four interrelated topics: etiology, patho- genesis, clinical manifestations, and treatment implications—the framework used throughout this textbook. Specific diseases will be used as illustrative examples of conditions in which particular pathophysiologic processes may occur.

FRAMEWORK FOR PATHOPHYSIOLOGY Etiology Etiology, in its most general definition, is the study of the causes or reasons for phenomena. A description of etiologic process includes the identification of those causal factors that, acting in concert, provoke a particular disease or injury. When the cause is unknown, a condition is said to be idiopathic. If the cause is the result of an unintended or unwanted medical intervention, the resulting condition is said to be iatrogenic. Most disorders are multifactorial, having several different etiologic factors that contribute to their development. For example, coronary heart disease is a result of the interaction of genetic predisposi- tion, diet, exposure to cigarette smoke, elevated blood pressure, and perhaps numerous other lifestyle and hormonal factors acting in concert. None of these individual factors can be said to cause the disease. When the link between an etiologic factor and development of a disease is less than certain but the probability is increased when the factor is

FIG 1.1 Colorized scanning electron micrograph of filamentous Ebola virus particles (blue) budding from a chronically infected VERO E6 cell (yellow-green). (From National Institute of Allergy and Infectious Diseases at http://flickr.com/photos/54591706@N02/14440817981. March 20, 2017.)

CHAPTER 1 Introduction to Pathophysiology 3

different stages. Knowledge of the possible stages of a disease is helpful in making an appropriate diagnosis and anticipating the clinical course.

Stages and Clinical Course Early in the development of a disease, the etiologic agent or agents may provoke a number of changes in biological processes that can be detected by laboratory analysis, although no recognition of these changes by the patient has occurred. The interval between exposure of a tissue to an injurious agent and the first appearance of signs and symptoms may be called a latent period or, in the case of infectious diseases, an incubation period. The prodromal period, or prodrome, refers to the appearance of the first signs and symptoms indicating the onset of a disease. Prodromal symptoms often are nonspecific, such as headache, malaise, anorexia, and nausea. During the stage of manifest illness, or the acute phase, the disease reaches its full intensity, and signs and symptoms attain their greatest severity. Sometimes during the course of a disease, the signs and symptoms may become mild or even disappear for a time. This interval may be called a silent period or latent period. For example, in the total-body irradiation syndrome, a latent period may occur between the prodrome and the stage of manifest illness. Another example is syphilis, which may have two latent periods: one occurring between the primary and secondary clinical stages and another occurring between the secondary and tertiary stages.

A number of diseases have a subclinical stage, during which the patient functions normally, although the disease processes are well established. It is important to understand that the structure and function of many organs provide a large reserve or safety margin, so that functional impairment may become evident only when organ damage has become advanced. For example, chronic renal disease can completely destroy one kidney and partly destroy the other before any symptoms related to a decrease in renal function are perceived.

The clinical course of a disease is often classified as acute or chronic. An acute condition has relatively severe manifestations but runs a short course measured in hours, days, or a few weeks. A chronic condition lasts for months to years. Sometimes chronic disease processes begin with an acute phase and become prolonged when the body’s defenses are insufficient to overcome the causative agent or stressor. In other cases, chronic conditions develop insidiously and never have an acute phase.

Some diseases (e.g., some types of autoimmune diseases) follow a course of alternating exacerbations and remissions. An exacerbation is a relatively sudden increase in the severity of a disease or any of its signs and symptoms. A remission is an abatement or decline in severity of the signs and symptoms of a disease. If a remission is permanent (sometimes defined as longer than 5 years), the person is said to be cured.

Convalescence is the stage of recovery after a disease, injury, or surgical operation. Occasionally a disease produces a subsequent pathologic condition called a sequela (plural: sequelae). For example, the sequela of an inflammatory process might be scarring. The sequelae of acute rheumatic inflammation of the heart might be scarring and deformation of cardiac valves. In contrast, a complication of a disease is a new or separate process that may arise secondarily because of some change produced by the original problem. For example, bacterial pneumonia may be a complication of viral infection of the respiratory tract.

Treatment Implications An understanding of the etiology, pathogenesis, and clinical consequences of a particular disorder may suggest, or “imply,” that certain treatments could be helpful. For example, understanding that a person with septic shock has excessive dilation of blood vessels that contributes to

pathogenesis is being increasingly understood on the cellular level. One of the best examples of this communication network is the immune system and its interactions with essentially every other cell in the body. A disruption in the delicate system of checks and balances between immune tolerance of normal cells and immune surveillance for abnormal cells and foreign antigens is at the root of a large number of degenerative and inflammatory diseases.

Pathologic disruptions in cellular behavior lead, in turn, to changes in organ and system function that may be detected by clinical or labora- tory examination. Most pathophysiology texts take a systems approach to presenting information. This approach builds on the way in which students learn anatomy and physiology and has its roots in medical specialization. Usually the clinical examination of a patient is also conceptualized by a systems approach. Although the division into systems is useful for dividing the content into conceptual pieces, it is important to remember that the organism functions as an integrated whole and the intercellular communication networks are not confined within single systems. In summary, pathogenesis is a description of how etiologic factors are thought to alter physiologic function and lead to the develop- ment of clinical manifestations that are observed in a particular disorder or disease.

Clinical Manifestations Manifestations of disease that are observed are termed signs of disease. Such objective data may be gathered by clinical examination or by biochemical analysis, diagnostic imaging, and other laboratory tests. The subjective feelings of an abnormality in the body are termed symptoms. By definition, symptoms are subjective and can only be reported by the affected individual to an observer. For example, the feeling of nausea is a symptom, whereas vomiting is objectively observed and is a sign. Some signs and symptoms, such as fever and headache, are nonspecific and, although they designate that something is amiss, they do not indicate a specific cause. In this case further examination and, often, laboratory tests are needed to focus on the possible causes of the signs and symptoms. Many diseases and disorders are characterized by a particular constellation of signs and symptoms, the knowledge of which is essential for accurate detection and diagnosis. When the etiology of a particular set of signs and symptoms has not yet been determined, the disorder may be termed a syndrome. For example, AIDS was originally detected as a set of signs and symptoms related to a deficiency of helper T cells of unknown cause, now known to be a late stage of HIV infection.

The clinical manifestations of some diseases may change significantly over time, resulting in a completely different clinical presentation at

Congenital (inborn) diseases or birth defects Degenerative diseases Iatrogenic diseases Idiopathic diseases Immunologic diseases Infectious diseases Inherited diseases Metabolic diseases Neoplastic diseases Nutritional deficiency diseases Physical agent–induced diseases Psychogenic diseases

BOX 1.1 Etiologic Classification of Diseases

4 UNIT I Pathophysiologic Processes

CONCEPTS OF NORMALITY IN HEALTH AND DISEASE The ability to measure numerous structural, physiologic, biochemical, and genetic parameters in an individual allows the evaluation of information that is helpful in the diagnosis and monitoring of clinical diseases. Many of these same measures are commonly used to screen for disease or to evaluate the risks of a disease occurring in the future. To determine whether a certain finding is indicative of disease or “abnormal,” it must be compared with what is “normal.” The obviousness of this statement belies the difficulty in determining what is normal and the degree of deviation from normal that would be considered abnormal. Many clinical parameters are evaluated by direct observation by the examiner. Skin color and warmth, quality of pulses, briskness of pupil reactions to light, mental acuity, muscle strength, joint mobility, heart sounds, lung sounds, bowel sounds, balance, psychological affect, and level of consciousness are but a few examples of assessments that are subjectively interpreted based on the examiner’s observations. Deciding whether a clinical finding is normal, a normal variation, or an abnormality indicative of a disorder is essential. Reliability of data obtained from observation is dependent on the examiner’s skill and experience. Often the clinical examination is not sufficient to determine definitively the underlying pathophysiologic processes, and diagnostic testing is undertaken to provide more information.

Statistical Normality Some of the variables that are measured to diagnose disease are relatively easy to declare as normal or abnormal because they occur in only two states; for example, a bone is either broken or not broken on x-ray examination. However, most diagnostic variables occur in the population according to a “bell curve,” or normal distribution. This means that a large enough sample taken from the population should give a good estimate of the range of values in the population. Statistics are often used to determine the standard deviation of the variable in question, and then a normal range is suggested as the mean ±2 standard deviations. This means that 95% of the values in the population are expected to fall in the normal range and 5% will be either higher or lower (Fig. 1.2). The “population” chosen to serve as the normal reference population

hypotension implies that fluid administration would likely be helpful. In contrast, most patients with cardiogenic shock have fluid overload, and hypotension in this case is unlikely to improve with fluid administra- tion. Care must be taken not to rely on theoretical implications when evidence-based treatment recommendations are available. When subjected to evaluation by rigorous randomized clinical trials, many treatments that seem as though they should help based on pathophysiology fail to pass the test of application.

The treatment implications discussed in pathophysiology texts usually are general statements rather than specific prescriptions. For example, the pathophysiology of heart failure is characterized by fluid overload, which implies that diuretic therapy would be useful; however, the exact selection of a drug and the dosing schedule would depend on a number of factors particular to the individual patient. Specific treatment recom- mendations are beyond the scope of a pathophysiology text and can be found in pharmacology and clinical practice textbooks.

KEY POINTS • Pathophysiology includes four interrelated topics: etiology, pathogenesis,

clinical manifestations, and treatment implications. • Etiology refers to study of the proposed cause or causes of a particular

disease process. Etiology is a complex notion because most diseases are multifactorial, resulting from interplay between genetic constitution and environmental influences.

• Pathogenesis refers to the proposed mechanisms whereby an etiologic stimulus leads to typically observed clinical manifestations. Pathogenesis describes the direct effects of the initiating event, as well as the usual physiologic responses and compensatory mechanisms.

• Clinical manifestations describe the signs and symptoms that typically accompany a particular pathophysiologic process. Manifestations may vary depending on the stage of the disorder, individual variation, and acuity or chronicity.

• An understanding of the etiology, pathogenesis, and clinical consequences of a particular disorder implies that certain treatments may be helpful.

Normal mean

Mean in those with disease

95% of values Variable values

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FIG 1.2 Representative example of a normal bell curve for a physiologic variable. Many physiologic variables are normally distributed within the population, so the mean ±2 standard deviations include 95% of the normal values in the sample. Approximately 2.5% of values will be above the normal range and 2.5% will be below it. There may be overlap between the values in a normal sample and those in the population with a disease, making interpretation difficult in some cases.

CHAPTER 1 Introduction to Pathophysiology 5

individual. The positive predictive value is an estimate of the probability that disease is present if the test is positive. The negative predictive value is an estimate of the probability that disease is absent if the test is negative. The predictive value of a test depends in part on the sensitivity and specificity of the test and in part on the probability of the disease being present before the test is obtained. Most tests are not perfectly specific and sensitive so the results must be interpreted probabilistically in view of the diagnostic hypotheses being tested.

Sensitivity and specificity are measures of how well a given test can discriminate between persons with and without a given condition. Sensitivity is the probability that the test will be positive when applied to a person with the condition. For example, if a kit for testing a throat swab for the presence of streptococcal infection has a sensitivity of 80%, then 20% of a group of people with streptococcal throat infection would erroneously test negative for the condition (false-negative rate). Another example is the blood test for HIV antibodies, which has a sensitivity of 99% and would fail to detect the condition in only 1% of a group of individuals who had HIV antibodies in their blood. Specificity is the probability that a test will be negative when applied to a person who does not have a given condition. If the streptococcal throat swab kit has a specificity of 95%, then 5% of those tested who do not actually have the condition would erroneously test positive (false-positive rate). The importance of evaluating the accuracy and precision of data is paramount because inappropriate diagnoses and clinical management could occur if decisions are predicated on invalid or unreliable data.

The positive predictive value of a test is improved when sensitiv- ity and specificity are high and the test is applied to individuals who have a high probability of having the condition being tested. If the likelihood of a condition in the population being tested is low (e.g., a 2% prevalence rate), then a positive result in a test with 99% specific- ity and 99% sensitivity would only have a 67% positive predictive value. This means that testing low-likelihood or low-risk individuals would produce a high percentage of false-positive results (33% in the preceding example). Therefore deciding who to test for a given condition based on the probability of the condition being present is as important as the sensitivity and specificity of the test. A good working knowledge of pathophysiology is necessary to generate the hypotheses that guide collection of appropriate data and facilitate the diagnostic process.

Individual Factors Influencing Normality Variations in physiologic processes may be a result of factors other than disease or illness. Age, gender, genetic and ethnic background, geographic area, and time of day may influence various physiologic parameters. Care must be taken to interpret “abnormal” findings with consideration of these possible confounding factors. In addition, the potential for spurious findings always exists. Thus trends and changes in a particular individual are more reliable than single observations. Single measure- ments, observations, or laboratory results that seem to indicate abnormality must always be judged in the context of the entire health picture of the individual. One slightly elevated blood glucose level does not mean clinical diabetes, a single high blood pressure reading does not denote hypertension, and a temporary feeling of hopelessness does not indicate clinical depression.

Cultural Considerations Each culture defines health and illness in a manner that reflects its experience. Cultural factors determine which signs, symptoms, or behaviors are perceived as abnormal. An infant from an impoverished culture with endemic chronic diarrhea and a degree of malnutrition would be viewed as abnormal in a progressive culture, such as a well-baby

must be carefully selected to represent the individual to be tested for disease, because many variables are influenced by age and gender.

For example, bone density can be measured in the population by radiologic imaging, and then a mean and standard deviation can be calculated. Women typically have lower bone density than men, and older women have lower bone density than younger women. If an elderly woman’s bone density is compared with women of her own age group, it may fall within the normal range, but compared with a group of younger women, it is more than 2 standard deviations below the mean. Which is the right comparison group to use to determine whether she has osteoporosis? There is controversy on this point because, in this situation, it is difficult to determine the difference between disease and the effects of normal aging.

Often, when assessing a person’s health status, a change in some value or factor is more significant than the actual value of the factor. A blood pressure of 90/70 mm Hg may not be significant if that is the usual value. However, if a person usually has a blood pressure of 120/80 mm Hg, a reading of 90/70 mm Hg could indicate a significant change. Individuals are typically evaluated more than once—generally two or three times—to establish deviation from their usual value.

Reliability, Validity, and Predictive Value The accurate determination of whether a specific condition is present or absent depends on the quality and adequacy of the data collected, as well as the skill of interpretation. Decisions about the data needed are based on the initial clinical presentation and a working knowledge of pathophysiology, which guide hypothesis generation about probable etiologies. During the clinical examination, data are analyzed, and a number of likely explanations for the clinical presentation may emerge. These possible explanations are “probabilities” based on knowledge and past experience with similar cases. The purpose of further data collection, particularly laboratory and diagnostic testing, is to refine the initial probability estimates and identify the most likely diagnosis. The success of this approach depends on the selection of appropriate tests based on the pretest probabilities, as well as on the validity, reliability, and predictive value of the tests.

Validity, or accuracy, is the degree to which a measurement reflects the true value of the object it is intended to measure. For example, a pulse oximeter is designed to measure arterial oxygen saturation, and the closeness of the reading to a direct measurement of oxygen saturation in an arterial blood sample reflects its accuracy. Reliability, or precision, is the ability of a test to give the same result in repeated measurements. An instrument or laboratory test can be reliable, yet inaccurate. Repeated measurements with the pulse oximeter could give the same result each time, but if those values are significantly different from the “gold standard” of an arterial blood sample, the oximeter data would have poor validity.

Some measurements vary according to the reagents and laboratory methods used. For example, prothrombin time (PT) is sensitive to the reagent used. In one method of determining PT, the reagent—a substance composed of thromboplastin and calcium—is added to decalcified plasma to create a reaction resulting in clot formation. The PT is then determined by measuring the length of time it takes for clotting to occur after this reagent is added and compared with the normative average. Portions of the same blood sample sent to several different laboratories could return significantly different PT results. In fact, this is such a problem that laboratories now use a correction procedure to normalize the PT values across labs. The corrected PT value is reported as the international normalized ratio (INR), which has higher reliability than the PT.

The predictive value of a test is the extent to which the test can differentiate between the presence and absence of a condition in an

6 UNIT I Pathophysiologic Processes

PATTERNS OF DISEASE IN POPULATIONS Concepts of Epidemiology Differences among individuals are, of course, very important in determin- ing the diseases to which they are susceptible and their reactions to the diseases once contracted. But epidemiology, or the study of patterns of disease involving aggregates of people (Fig. 1.4), provides yet another important dimension. Information may be gained by examining the occurrence, incidence, prevalence, transmission, and distribution of diseases in large groups of people or populations.

clinic in Sweden. Given cultural variations that affect definitions of normal and abnormal, the resulting pattern of behaviors or clinical manifestations affects what the culture labels as illness.

Age Differences Many biological factors vary with age, and the normal value for a person at one age may be abnormal at another. Physiologic changes, such as hair color, skin turgor (tension), and organ size, vary with age. In general, most organs shrink; exceptions are the male prostate and the heart, which enlarge with age. Special sensory changes, such as severely diminished near-sight, high-tone hearing loss, and loss of taste dis- criminations for sweet and salty, are normal in an elderly adult and abnormal in a middle-aged adult or child. There are fewer sweat glands and less thirst perception in an elderly person than in a young adult or child. Elderly persons have diminished temperature sensations and can therefore sustain burn injuries—from a heating pad or bath water—because they do not perceive heat with the same intensity as do middle-aged adults. A resting heart rate of 120 beats per minute is normal for an infant but not for an adult.

Gender Differences Some laboratory values, such as levels of sex and growth hormones, show gender differences. The complete blood cell count shows differences by gender in hematocrit, hemoglobin, and red blood cell (RBC) count. For example, the normal range of hemoglobin concentration for adult women is lower than that for adult men—for adult women, the normal hemoglobin range is 12 to 16 g/100 mL of blood, whereas for adult men the normal range is 13 to 18 g/100 mL of blood. There are also gender differences in the erythrocyte sedimentation rate (ESR). Normally, in males, the ESR is less than 13 mm/hr; it is slightly higher in females. There are differences by gender in creatinine values too. For females, the normal serum creatinine level is 0.4 to 1.3 mg/dL; for males, the normal range is 0.6 to 1.5 mg/dL. Research into gender differences also suggests that, on average, males snore more; have longer vocal cords, better daylight vision, and higher metabolic rates; and are more likely to be left-handed than females. Research suggests, too, that females and males may have different communication styles and respond differently to similar conditions.

Situational Differences In some cases, a deviation from the usual value may occur as an adaptive mechanism, and whether the deviation is considered abnormal depends on the situation. For example, the RBC count increases when a person moves to a high altitude. The increase is a normal adaptive response to the decreased availability of oxygen at a high altitude and is termed acclimatization. A similar increase in the RBC count at sea level would be abnormal.

Time Variations Some factors vary according to the time of day; that is, they exhibit a circadian rhythm or diurnal variation. In interpreting the result of a particular test, it may be necessary to know the time at which the value was determined. For example, body temperature and plasma concentra- tions of certain hormones (such as growth hormone and cortisol) exhibit diurnal variation. Reflecting fluctuation in plasma levels, the peak rate in urinary excretion for a particular steroid (17-ketosteroid) occurs between 8 AM and 10 AM for persons who customarily rise early in the morning and is about two to three times greater than the lowest rate in the same people, which occurs between midnight and 2 AM, usually during sleep. The urinary excretion of ions (e.g., potassium) also exhibits diurnal variation. Fig. 1.3 illustrates circadian rhythms of several physi- ologic variables for persons living on a standard day-active schedule.

0 12 Circadian time (hours)

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FIG 1.3 Circadian rhythms of several physiologic variables in a human subject depict the effect of light and dark. In an experiment with lights on (open bars at top) for 16 hours and off (black bars at top) for 8 hours, temperature readings and plasma growth hormone, plasma cortisol, and urinary potassium levels exhibit diurnal variation. (Redrawn from Vander AJ et al: Human physiology, ed 7, New York, 1998, McGraw-Hill.)

KEY POINTS • Determining whether clinical findings are normal, abnormal, or a normal

variation is an essential, but often difficult, process in evaluating for the presence or absence of disease.

• Normal ranges for laboratory tests are typically defined as the mean ±2 standard deviations; thus 5% of the normal population may fall outside the normal range despite the absence of disease. Laboratory tests must be evaluated in concert with clinical information.

• The predictive value of a clinical test is the extent to which it can differentiate between the presence and absence of disease in an individual. Tests with high sensitivity and specificity generally have better predictive value.

• Variations in physiologic processes may be a result of factors other than disease or illness. Age, gender, genetic and ethnic background, geographic area, and time of day may influence various physiologic parameters.

• Trends and changes in a particular individual are more reliable than single observations.

CHAPTER 1 Introduction to Pathophysiology 7

Age. In one sense, life is entirely different during the 9 months of gestation. The structures and functions of tissues are different: they are primarily dedicated to differentiation, development, and growth. Certainly the environment is different; the individual is protected from the light of day, provided with predigested food (even preoxygenated blood), suspended in a fluid buffer, and maintained at incubator temperature. This is fortunate because the developing embryo or fetus has relatively few homeostatic mechanisms to protect it from environmental change. (The factors that produce disease in utero are discussed in Chapter 6.) Diseases that arise during the postuterine period of life and affect the neonate include immaturity, respiratory failure, birth injuries, congenital malformations, nutritional problems, metabolic errors, and infections. These conditions are discussed in separate chapters.

Accidents, including poisoning, take their toll in childhood. Infections in children reflect their increased susceptibility to agents of disease. Consideration of other childhood diseases is addressed in each chapter as appropriate and given separate consideration throughout the text. The study of childhood processes and of changes that occur in this period of life is the domain of pediatrics; specific diseases that occur during maturity (ages 15 to 60) are emphasized in this text.

The changes in function that occur during the early years of life are termed developmental processes. Those that occur during maturity and postmaturity (age 60 and beyond) are called aging processes. The study of aging processes and other changes that occur during this period of life is called gerontology. The effects of aging on selected body systems are so important physiologically that they also receive separate consid- eration throughout the text. The immune, cardiac, respiratory, musculoskeletal, neurologic, special sensory, endocrine, gastrointestinal, and integumentary systems are among those affected by the process of aging.

Ethnic group. It is difficult to differentiate precisely between the effects of ethnicity on patterns of disease and the socioeconomic factors, religious practices, customs, and geographic considerations with which ethnicity is inseparably bound. For example, carcinoma of the penis is virtually unknown among Jews and Muslims who practice circumcision at an early age (avoiding the carcinogenic stimulus that arises from accumulation of smegma about the glans penis).

However, comparisons reveal significant differences in the occur- rence of certain disease states in ethnic groups that seem to be more closely related to genetic predisposition than to environmental factors. For example, sickle cell anemia has a much higher rate of occurrence in African populations, whereas pernicious anemia occurs more frequently among Scandinavians and is rare among black populations worldwide.

The study of racial and ethnic group variation in disease states is the domain of medical anthropology. Disease-specific differences that relate to racial or ethnic group differences are a developing research frontier. In clinical practice, recognition of diversity in disease risk by racial or ethnic group is useful in disease diagnosis, prevention, and management. Ethnic group–specific differences, where important, are presented in individual chapters.

Gender. Particular diseases of the genital system obviously show important differences between the sexes; men do not have endometriosis, nor do women have hyperplasia of the prostate, and carcinoma of the breast is more common in women than in men. Pyelonephritis is more common in young women than in men of comparable age (before they develop prostatic hyperplasia) because the external urethral orifice of women is more readily contaminated, and bacteria can more easily travel up a short urethra than a long one. Less obviously related to the reproductive system, the onset of severe atherosclerosis in women is delayed nearly 20 years or more over that in men, presumably because of the protective action of estrogenic hormone.

Endemic, Pandemic, and Epidemic Diseases A disease that is native to a local region is called an endemic disease. If the disease is disseminated to many individuals at the same time, the situation is called an epidemic. Pandemics are epidemics that affect large geographic regions, perhaps spreading worldwide. Because of the speed and availability of human travel around the world, pandemics are more common than they once were.

Almost every flu season, a new strain of influenza virus quickly spreads from one continent to another. The 2014–2015 Ebola epidemic in West Africa provides an excellent example of an epidemic that spread worldwide, becoming pandemic. The first case was reported in Guinea in March 2014, and the disease spread in the neighboring countries of Liberia and Sierra Leone. Over the span of a year, the Ebola pandemic caused more than 10 times as many cases of Ebola than the combined total of all those reported in previous Ebola outbreaks. As the outbreak became more widespread, travel-associated cases appeared in Nigeria, Mali, Senegal, and countries outside Africa, including the United States.

Aggregate Factors Principal factors affecting patterns of disease in human populations include the following: (1) age (i.e., time in the life cycle), (2) ethnic group, (3) gender, (4) socioeconomic factors and lifestyle considerations, and (5) geographic location.

B

A

FIG 1.4 A, The aggregate focus in disease: influence of crowds on disease transmission. Crowd gathered at a public market in Russia. B, Crowds gathered to purchase goods at a public market in Guangzhou, China. (Photographed by L-E Copstead.)

8 UNIT I Pathophysiologic Processes

hospital-acquired infections have become resistant to at least one of the drugs commonly used to manage them, largely attributable to the overprescribing of antibiotics. Staphylococcus, the leading cause of hospital infections, is now resistant to 95% of first-choice antibiotics and 30% of second-choice antibiotics. Poor hand hygiene is considered the leading source for infections acquired during hospitalizations. Unfortunately, efforts to convince health care personnel to reduce transmission of infection through practices as simple as more frequent and thorough handwashing have met with only modest success.

The incidence of many parasitic diseases is closely tied to socioeco- nomic factors and lifestyle considerations. Worm infections, for example, are related to the use of human feces as fertilizer. In some areas, such as parts of Asia, Africa, and tropical America, the frequency of schis- tosomiasis (a parasitic infestation by blood flukes) is directly related to the widespread use of irrigation ditches that harbor the intermediate snail host. There is adequate opportunity for transmission of schisto- somiasis because children often play in these ditches, and families wash their clothes in ditch water (Fig. 1.5).

Trichinosis, a disease caused by the ingestion of Trichinella spiralis, occurs almost entirely from eating inadequately cooked, infected pork. People who are fond of raw meat and inadequately cooked sausage are at highest risk.

Education is often very effective in changing lifestyle patterns that contribute to disease. In Tokyo, for example, mass public education about minimizing the use of sodium—a common ingredient in most traditional Japanese cooking—has been effective in changing dietary practices.

Examples of educational efforts directed at lifestyle modification in the United States are numerous. Antidrug, antismoking, and profitness messages fill the media and are prevalent on the Internet. Choosing

However, some gender-specific factors defy explanation. For example, systemic lupus erythematosus is much more common in women. Toxic goiter and hypothyroidism are also more common in women. Rheu- matoid arthritis is more common in women, but osteoarthritis affects men and women with equal frequency. Thromboangiitis obliterans (a chronic, recurring, inflammatory peripheral vascular disease) occurs more commonly in men. Gender differences in predisposition to cancer and other diseases, where relevant, are presented throughout the text.

Socioeconomic factors and lifestyle considerations. The environ- ment and the political climate of countries determine how people live and the health problems that are likely to ensue. The importance of poverty, malnutrition, overcrowding, and exposure to adverse environ- mental conditions, such as extremes of temperature, is obvious. Volumes have been written about the effects of socioeconomic status on disease. Sociologists study the influence of these factors. Social class influences education and occupational choices.

Disease is related to occupational exposure to such agents as coal dust, noise, or extreme stress. Lifestyle considerations are closely related to socioeconomic factors. Many people living in the United States, for example, consume too much food, alcohol, and tobacco and do not exercise enough. Childhood obesity is a problem in the United States and is becoming a global problem as well. Arteriosclerosis; cancer; diseases of the kidney, liver, and lungs; and accidents cause most deaths in the United States. By contrast, people living in developing nations suffer and frequently die of undernutrition and infectious diseases.

However, infectious disease is not limited to developing countries. The Centers for Disease Control and Prevention (CDC) estimates that 2 million people annually acquire infections while hospitalized, and 90,000 people die as a result of those infections. More than 70% of

A B

FIG 1.5 Risk factors for schistosomiasis include the widespread use of irrigation ditches that harbor the intermediate snail host. (Photographed in China by L-E Copstead.)

CHAPTER 1 Introduction to Pathophysiology 9

bedding, needles, syringes/sharps, or medical equipment) that have been contaminated with infected body fluids. Additionally, people can become sick with Ebola after coming in contact with infected wildlife. In Africa, Ebola may spread as a result of handling bushmeat (wild animals hunted for food) and contact with infected bats.

The World Health Organization (WHO) and the National Institutes of Health (NIH) have been deeply concerned with geographic problems in disease. Consult WHO and NIH home pages on the World Wide Web for additional information. (Web locations are provided on the Evolve website.)

Levels of Prevention The goal of health care should encompass much more than the prevention of illness. What is needed instead is some notion of positive health or physical “wholeness” that extends beyond the absence of ill health. The WHO defines health as complete physical, mental, and social well-being and not merely the absence of disease or infirmity. For some individuals, health implies the ability to do what they regard as worthwhile and to conduct their lives as they want. Aging and ill health are not synonymous, and many elders enjoy excellent health, even in the face of chronic disease (Fig. 1.7).

Epidemiologists suggest that treatment implications fall into categories called levels of prevention. There are three levels of prevention: primary, secondary, and tertiary. Primary prevention is prevention of disease by altering susceptibility or reducing exposure for susceptible individuals. Secondary prevention (applicable in early disease, i.e., preclinical and clinical stages) is the early detection, screening, and management of the disease. Tertiary prevention (appropriate in the stage of advanced disease or disability) includes rehabilitative and supportive care and attempts to alleviate disability and restore effective functioning.

Primary prevention. Prolongation of life has resulted largely from decreased mortality from infectious disease. Primary prevention in terms of improved nutrition, economy, housing, and sanitation for those living in developed countries is also responsible for increased longevity. Certain childhood diseases—measles, poliomyelitis, pertussis (whooping cough), and neonatal tetanus—are decreasing in prevalence, due to a rapid increase in coverage by immunization programs. More than 120 million children younger than age 5 in India were immunized against polio- myelitis in a single day in 1996. Globally, coverage of children immunized against six major childhood diseases increased from 5% in 1974 to 80% in 1995. In 1985 Rotary International launched the PolioPlus program to protect children worldwide from the cruel and fatal consequences of polio. In 1988 the World Health Assembly challenged the world to eradicate polio. Since that time, Rotary International’s efforts and those of partner agencies, including the WHO, the United Nations Children’s Fund, the CDC, and governments around the world, have achieved a significant reduction in the number of polio cases worldwide. Although the partners had pledged to wipe out the polio virus by 2018, that would have meant that transmission of the virus would have to be stopped by the end of 2015, because eradication may be certified by the WHO only 3 years after the last case.

As of September 2015, 41 cases were reported: 32 in Pakistan and 9 in Afghanistan. Some of the strategies used in Nigeria, which ended polio as of 2015, are now being implemented in Pakistan. But violence against vaccinators remains a serious obstacle.

The prevalence of cardiovascular diseases in developed countries (except those in Eastern Europe) is diminishing, thanks to the spread of health education and promotion. Infant and child death rates and the overall death rate are continuing to decrease globally.

High school health education programs are other examples of primary prevention efforts. Primary prevention also includes adherence to safety precautions, such as wearing seat belts, observing the posted speed limit

healthy alternatives over unhealthy ones is made easier through positive peer pressure and support groups.

Geographic location. Patterns of disease vary greatly by geographic location. Certainly there is considerable overlap with ethnicity, socio- economic factors, and lifestyle choices, but physical environment also is an important aspect. Obviously, frostbite in Antarctica and dehydration in the Sahara are examples of disorders that are more prevalent in specific geographic settings. However, important patterns of disease occur within individual countries. For example, the incidence and type of malnutrition vary tremendously by geographic region.

Many diseases have a geographic pattern for reasons that are clear. For example, malaria, an acute and sometimes chronic infectious disease resulting from the presence of protozoan parasites within red blood cells, is transmitted to humans by the bite of an infected female Anopheles mosquito. The Anopheles mosquito can live only in certain regions of the world (Fig. 1.6).

Fungal diseases are both more common and more serious in hot, humid regions. But some infectious diseases are highly limited geographi- cally for reasons that are not well understood. For example, bartonellosis, which is also called Carrión disease, is found only in Peru, Ecuador, Chile, and Colombia. This disease resembles malaria superficially in that the minute rickettsia-like organisms invade and destroy erythrocytes. Humans are infected by the bite of the sand fly. Although conditions in other parts of the world should be favorable for this disease, it remains limited geographically.

Ebola was first discovered in 1976 near the Ebola River in what is now the Democratic Republic of the Congo. Since then, outbreaks have appeared sporadically in Africa. The natural reservoir host of Ebola virus remains unknown. However, on the basis of evidence and the nature of similar viruses, researchers believe that the virus is animal-borne and that bats are the most likely reservoir. Four of the five virus strains occur in an animal host native to Africa.

Taking a world view, there is widespread recognition of the importance of geographic factors in influencing human disease. For example, health care providers caring for Ebola patients and family and friends in close contact with Ebola patients are at the highest risk of getting sick because they may come in contact with infected blood or body fluids. Ebola also can be spread through direct contact with objects (like clothes,

Distribution of falciparum malaria

FIG 1.6 Geographic distribution of malaria. (From Centers for Disease and Control Prevention. https://www.cdc.gov/malaria/about/distribution. html. April 27, 2017.)

10 UNIT I Pathophysiologic Processes

ascertain gender, and to measure substances associated with defects in the spinal cord and brain.

Tertiary prevention. Once a disease becomes established, treatment— within the context of traditional Western medicine—generally falls into one of the following two major categories: medical (including such measures as physical therapy, pharmacotherapy, psychotherapy, radiation therapy, chemotherapy, immunotherapy, and experimental gene therapy) and surgical. Numerous other subspecialties of medicine and surgery also have evolved to focus on a given organ or technique. In a clinical setting, a large array of professional caregivers provides rehabilitative and supportive tertiary prevention to the affected individual. Every professional brings the perspective of his or her discipline to the caregiv- ing situation. Each makes clinical judgments about the patient’s needs and problems and decides which goals and intervention strategies are most beneficial.

on highways, and taking precautions in the use of chemicals and machinery. Violent crimes involving dangerous weapons must be stopped to achieve primary prevention of the traumatic or fatal injuries they cause.

Environmental pollutants, such as benzene, mold, asbestos, and lead, poison the body’s organs. Some experts fear the emergence of an epidemic of cancer attributable to the carcinogenic chemicals afflicting the environment. Public health measures to ensure clean food, air, and water prevent many diseases, including cancer. As air, water, and soil quality is improved, the risk of exposure to harmful carcinogens is minimized.

Secondary prevention. Yearly physical examinations and routine screening are examples of secondary prevention that lead to the early diagnosis of disease and, in some cases, cures. The routine use of Pap smears has led to a decline in the incidence of invasive cancer of the uterine cervix. Also, more women are examining their own breasts monthly for cancer; thus earlier diagnoses are achieved.

Prenatal diagnosis of certain genetic diseases is possible. New diagnostic laboratory techniques provide definitive information for the genetic counseling of parents. This information can aid in predicting chances of involvement or noninvolvement of offspring for a given genetic disorder.

Amniocentesis is a diagnostic technique that consists of removing a small amount of fluid from the amniotic sac that surrounds the fetus and analyzing the cells and chemicals in the fluid. Blood samples can also be obtained from the fetus by amniocentesis; the amniotic fluid and fetal blood are then studied to determine defects in enzymes, to

A B

FIG 1.7 Healthy aging: elders exercising in an aerobics class (A) and painting (B) illustrate the concept that aging and disease are not synonymous. The artist, a healthy woman in her mid-70s, is also a breast cancer survivor. (Photographed by Therese A. Capal, Rockville, MD.)

KEY POINTS • Epidemiology is the study of patterns of disease in human populations. • Diseases may be endemic, epidemic, or pandemic depending on location

and the number of people affected. • Aggregate factors such as age, ethnicity, gender, lifestyle, socioeconomic

status, and geographic location are epidemiologic variables that influence the occurrence and transmission of disease in populations.

• Understanding the epidemiologic aspects of a disease is essential for effective prevention and treatment.

Most people recognize what it is to be healthy and would define disease or illness as a change from or absence of that state. Under closer scrutiny, the concept of health is difficult to describe in simple, succinct terms. Correspondingly, the concepts of disease and illness also are complex. Environment, genetic constitution, socioeconomic status, lifestyle, and previous physical health all affect the timing and ultimate expression of disease in individuals.

Because humans exhibit considerable diversity, healthy structure and function are not precisely the same in any two individuals. By discovering common and expected patterns of responses to abnormalities, general prediction of etiology, pathogenesis, clinical manifestations, and targeted levels of prevention and intervention becomes possible.

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CHAPTER 1 Introduction to Pathophysiology 11

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12

2 Homeostasis, Allostasis, and Adaptive Responses to Stressors Debra A. Jansen and Roberta J. Emerson

K E Y Q U E S T I O N S • What is the relationship between homeostasis and allostasis? • How do the sympathetic nervous system and neuroendocrine

system respond to stress? • What are the key features of Selye’s General Adaptation

Syndrome?

• What factors affect the stress response? • How does allostatic overload contribute to the development of

disease?

C H A P T E R O U T L I N E Homeostasis and Allostasis, 12

Homeostasis, 12

Allostasis, 13

Stress as a Concept, 13 The General Adaptation Syndrome and Allostasis, 14

Alarm Stage, 14 Resistance or Adaptation Stage, 14 Exhaustion Stage, 16

Stressors, Gender and Developmental Influences, and Risk Factors, 16

Neurohormonal Mediators of Stress and Adaptation, 17 Catecholamines: Norepinephrine and Epinephrine, 17

Adrenocortical Steroids: Cortisol and Aldosterone, 18

Endorphins, Enkephalins, and Immune Cytokines, 19

Sex Hormones: Estrogen, Testosterone, and Dehydroepiandrosterone, 19

Growth Hormone, Prolactin, and Oxytocin, 19

Adaptation, Coping, and Illness, 20 Adaptation, Coping, and Resilience, 20

Allostatic Overload and Illness, 21

http://evolve.elsevier.com/Banasik/pathophysiology/

Humans, like all living organisms, must be able to respond and adapt to alterations in the environment. Changes in the external environment, such as moving outside from a warm house on a cold winter day, demand physiologic adjustments in the body’s internal environment beyond the simple addition of layers of clothing to the outside of the body. Variations in the internal environment, such as a fever caused by infection, also necessitate physiologic responses to return the body’s temperature to the normal range. The human organism maintains a variety of highly complex interactions with both internal and external environments. These interactions facilitate ongoing compensatory changes designed to support the organism physically and psycho- logically. Compensatory changes are necessary because they allow the perpetuation of both the individual and the species. Researchers, however, have found that the body’s efforts to adapt to prolonged and repeated or extraordinarily demanding environmental changes may be associated with many physical and psychological health problems. This chapter explores the historical and current perspectives of homeostasis, allostasis, and stress responses and their relationship to health and illness.

HOMEOSTASIS AND ALLOSTASIS Homeostasis The word homeostasis is derived from the Greek words homeo, or similar, and stasis, or standing still, and means maintaining internal conditions in a stable state by keeping parameters relatively the same. Homeostasis often is conceptualized as a state of being in which all systems are in balance around a particular ideal “set-point.” From this perspective, bodily changes formerly seen as conflicting or detrimental are understood as adaptive or compensatory to the maintenance of homeostasis within the body as a whole. Homeostasis reflects a tendency to stabilize an organism’s functional systems, despite changes both internally and externally. Deviations from homeostasis resulting from these changes require elaborate systems to support the return of balance to the body. Over the past several decades, the definition of homeostasis has been criticized as being inadequate in encompassing the entire process of maintaining a stable state in complex organisms. But the fact remains that homeostatic concepts are an essential starting point for an explora- tion of stress, adaptation, and disease.

• Review Questions and Answers • Glossary (with audio pronunciations for selected terms) • Animations

• Case Studies • Key Points Review

CHAPTER 2 Homeostasis, Allostasis, and Adaptive Responses to Stressors 13

and stasis, meaning standing still. Therefore this term accentuates the role of allostatic systems in maintaining the organism’s stability by varying or changing. Allostasis is a dynamic process that supports and helps the body achieve a steady-state. In essence, the organism’s overall stability is accomplished through change.

Allostasis involves intricate regulatory processes orchestrated by the brain. Through these processes, the body’s parameters are continuously reevaluated and readjusted to match resources to the needs dictated by the situation. These parameter readjustments (e.g., of heart rate, blood pressure, or glucose levels) entail altering multiple set-points such that the person may be functioning at reduced or elevated levels or rates for numerous physiologic variables. Thus an individual may have different set-points for different circumstances (e.g., when resting versus running or when healthy versus sick). Allostasis comes into play in the complexity of social interactions and in our responses to adverse childhood experiences and low socioeconomic status (SES), exposure to environmental pollutants, and the demands of everyday modern living and working conditions, as well as in critical illness. The concept has garnered broad support in both the physical and the behavioral sciences. It seems especially applicable to subsequent discussions of adaptation and disease.

Claude Bernard, a nineteenth-century French physiologist, is credited with describing the basic premise of homeostasis. He believed that the various vital physiologic mechanisms of the body had as their goal the maintenance of a uniform and constant internal environment, or milieu intérieur, for the body. The stability of the internal environment was deemed necessary for the survival of the person, independent or free of the external environment. Disease occurred when the body did not respond appropriately to maintain internal stability when threatened by perceived or actual events. Building on Bernard’s work, Walter B. Cannon created a concept that he referred to as homeostasis in his 1932 book The Wisdom of the Body. Homeostasis, according to Cannon, was a process in which each of the body’s biochemical or physiologic variables (e.g., body temperature; oxygen, sodium, calcium, and glucose levels; and pH) was maintained within a narrow set-point range. Negative feedback loops sensed and corrected deviations from the set-point ranges for the variables, thereby supporting the survival of the individual, despite threats from the external or internal environments. These environmental threats could range from temperature extremes and water loss or gain, to “savage creatures” and bacterial infections. Box 2.1 provides examples of homeostatic systems designed to support the life of the person in the most basic sense.

Allostasis The original concept of homeostasis, with the principle that the body attempts to achieve balance around a single optimal level or set-point for a given physiologic variable, has been challenged in recent decades. The innate complexity of biological organisms requires that set-points be readjusted for different circumstances (i.e., diverse situations neces- sitate different homeostatic set-points), including the anticipation of increased demands. For example, respiratory rate needs to increase when vigorously exercising or when ill with pneumonia to obtain more oxygen. At the same time, when responding to an internal or external environmental challenge (i.e., a stressor), multiple physiologic parameters may have to raise or lower their levels or actions to meet the demands posed by the challenge. Useful changes in one body system, though, may be detrimental to another, especially if prolonged; these changes, however, may ultimately be needed to support the survival of the organism as a whole at that particular point in time. For instance, in shock, when the life of the organism is at risk, blood flow to essential organs (brain and heart) is maintained by reducing perfusion to the kidneys, skin, and gastrointestinal tract. Simply stated, the body is not concerned about digesting dinner or making urine when it is trying to divert resources to a struggling brain and heart.

In 1988 Sterling and Eyer introduced the concept of allostasis in recognition of the complexity and variable levels of activity necessary to reestablish or maintain homeostasis. They described allostasis as the ability to successfully adapt to challenges. To survive, “an organism must vary all the parameters of its internal milieu and match them appropriately to environmental demands.” Like homeostasis, allostasis is a derivation of the Greek words allo, meaning variable or different,

Baroreceptor response to acute changes in blood pressure Vasopressin/antidiuretic hormone release from the posterior pituitary in response

to changes in serum osmolality Hypothalamic-mediated responses to changes in body core temperature Central chemoreceptor responses to changes in PaCO2 Parathyroid gland response to changes in serum calcium level

BOX 2.1 Examples of Homeostatic Systems

KEY POINTS • Contemporary concepts of homeostasis have a long history, reaching back

to the ancient Greeks. • Homeostasis is a state of equilibrium, of balance within the organism. • Homeostatic responses refer to systems whose purpose is specifically to

normalize selected physiologic variables. • Allostasis is the overall process of adaptive change necessary to maintain

survival and well-being. • Allostasis may involve altering multiple physiologic variables to match the

resources of the body to environmental demands. It helps the body achieve homeostasis.

STRESS AS A CONCEPT Referring to stress as an “ambiguous” term is an understatement. Its ubiquitous use in everyday parlance is matched by its frequent presence in the health and psychology literature. Stress often is interpreted as a physical, chemical, or emotional factor that produces tension in the body or the mind (“He’s experiencing a lot of stress”). But it also can mean the actual physical and mental state of tension (“I feel stressed”). Others use the term stress in relation to the response by the body to internal and external demands. Stress can be defined as a real or perceived threat to the balance of homeostasis. The neuroendocrinologist Robert Sapolsky more specifically distinguishes between the stress terminology and defines a stressor as anything that throws the body out of allostatic balance, whereas the stress response is the body’s effort to try to restore the balance. To that end, stress is a natural outgrowth of the concept of homeostasis, but is even more applicable to the dynamic concept of allostasis. Sapolsky’s definition also underscores an important point: The stress response by the body is meant to be helpful, at least in the short term; however, it becomes damaging when repeatedly activated or when it does not cease.

As early as the 1920s, Walter Cannon used the term stress in relation to humans and medicine. Hans Selye, however, often is erroneously credited with being the first person to borrow the term from the fields of engineering and physics and apply it to the human condition. In the

14 UNIT I Pathophysiologic Processes

enable the body to rapidly take action to fight or flee the stressor. This series of events is part of the sympathetic-adrenal-medullary system, originally referred to as the fight-or-flight response by Walter Cannon. Additionally, the hypothalamus secretes CRH to stimulate the anterior pituitary gland to release adrenocorticotropic hormone (ACTH). ACTH then causes the adrenal cortex (the outer portion of the adrenal gland) to release substantial amounts of the glucocorticoids, specifically cortisol, eliciting its diverse responses. This cascade of effects is termed the hypothalamic-pituitary-adrenal (HPA) axis. Once the pituitary gland is activated, the alarm stage progresses to the stage of resistance. This coordinated systemic response to stress is illustrated in Fig. 2.2.

Allostasis is essentially the activation of these stress responses to evoke changes that return the organism to homeostasis. Mediators of allostasis include the aforementioned hormones and neurotransmitters of the HPA axis and the sympathetic-adrenal-medullary system (e.g., cortisol, epinephrine, and norepinephrine), various other hormones presented later in this chapter, and also cytokines from the immune system. The alarm stage of the stress response with the release of its various substances is meant to be helpful to the organism in overcoming the stressor.

Resistance or Adaptation Stage If the alarm stage were to persist, the body would soon suffer undue wear and tear and become subject to permanent damage and even death. To survive, the body must move beyond the alarm stage to a stage of resistance (also called adaptation) supportive of the allostatic return to a state of homeostasis. As the body moves into the stage of resistance, the sympathetic nervous system and adrenal medulla and cortex are functioning at full force to mobilize resources to manage the stressor. The resources include glucose, free fatty acids, and amino acids. Concentrations of these chemicals are elevated through the effects of cortisol and the catecholamines (i.e., epinephrine and norepinephrine). These resources are used for energy and as building blocks, especially the amino acids, for the later growth and repair of the organism after

1930s Selye was experimenting with assorted ovarian and placental hormonal preparations and other tissue extracts and toxic agents. He was injecting these into rats when he serendipitously uncovered a biologi- cal basis for stress. Selye was expecting to find different physiologic responses in the rats, depending on which of the various substances was injected; however, to his surprise and disappointment, the same three changes occurred each time. In every animal tested, the cortex of the adrenal gland enlarged, lymphatic organs (thymus, spleen, and lymph nodes) shrank, and bleeding peptic ulcers developed in the stomach and duodenum. When Selye experimented with other noxious stimuli, such as exposing the rats to temperature extremes, surgery, or forced exercise, the same three changes occurred. Any kind of harmful physical stimuli he used produced the same observed physiologic changes. Selye termed the harmful stimuli or causative agents stressors and concluded that the changes observed represented a nonspecific response by the body to any noxious stimulus or demand, a general “stress” response. Because so many different agents caused the same changes, Selye called this process a general adaptation syndrome (GAS) with three components: an alarm reaction, a stage of resistance, and a stage of exhaustion. According to Selye, when confronted by stressors during daily life, individuals move through the first two stages repeatedly and eventually become adapted and “used to” the stressors.

Selye’s original conceptualization of the stress response and GAS has been criticized as being too simplistic for the complexities of humans. In particular, evidence suggests the body does not produce the same responses to all types of stressors. Depending on the type and severity of stressor, different patterns of hormone release occur, with more of some substances and less of others being produced and at different speeds and for varying lengths of time. Moreover, Selye’s early work in the 1930s concentrated on stimuli of a physical or biological nature. Beginning in the 1970s, researchers began to realize that perception of these stimuli was important to individuals’ responses to stress and that responses could be physiologic, as Selye described, as well as behavioral in nature. When stress is generated by extreme psychological or envi- ronmental demands, balance is disrupted, and allostatic reactions are initiated to restore balance. The discussion that follows presents the GAS as a reflection of the responses to these diverse stimuli and incorporates much of the knowledge acquired since Selye’s early pioneer- ing work.

The General Adaptation Syndrome and Allostasis Components of the GAS can be subdivided into three unique, largely physiologic stages (Table 2.1). Examining the stages separately is the best way to understand the entire GAS. The specific chemicals involved are among those seen today as integral to the broader view of allostatic responses to stress in the maintenance of homeostasis. All will be discussed later in the chapter.

Alarm Stage The alarm stage has been called the fight-or-flight response, derived from Cannon’s work, because it provides a surge of energy and physical alterations to either evade or confront danger (Fig. 2.1). This stage begins when the hypothalamus, as it monitors the internal and external environment, senses a need to activate the GAS in response to a stimulus, a stressor placing the balance of homeostasis at risk. The stressor might be physical or emotional, positive or negative—arguing with a friend, having an upper respiratory tract infection, running to catch a bus, or winning the lottery. The hypothalamus then secretes corticotropin-releasing hormone (CRH) to activate the sympathetic nervous system (SNS), which in turn also stimulates the adrenal medulla (the inner portion of the adrenal gland) to release the catecholamines— norepinephrine and epinephrine. The increased levels of catecholamines

TABLE 2.1 Stages of the General Adaptation Syndrome

Alarm Resistance Exhaustion

Increased secretion of glucocorticoids and responses

Eventual normalization of glucocorticoid secretion

Increased glucocorticoid secretion followed by significant dysregulation

Increased sympathetic nervous system activity

Eventual normalization of sympathetic nervous system activity

Diseases of adaptation

Increased secretion of epinephrine (and some norepinephrine) from adrenal medulla

Eventual normalization of epinephrine and norepinephrine secretion from adrenal medulla

Loss of resistance to stressor; possible death of organism

Fight-or-flight manifestations

Resolution of fight-or-flight manifestations

Reduced resistance to stressors

Increased resistance (adaptation) to stressor

CHAPTER 2 Homeostasis, Allostasis, and Adaptive Responses to Stressors 15

Hypothalamus senses a stressful stimulus in the internal or external environment

Sympathetic nervous system and adrenal medulla secrete

catecholamines (epinephrine and norepinephrine)

Hypothalamus secretes corticotropin-releasing hormone

Hypothalamus secretes corticotropin-releasing hormone

Anterior pituitary secretes adrenocorticotropic hormone

Adrenal cortex secretes corticosteroids (cortisol

and aldosterone)

FIG 2.1 Steps of Selye’s alarm stage of the general adaptation syndrome. (Modified from McKenry L et al: Mosby’s pharmacology in nursing, ed 22, St Louis, 2006, Mosby.)

Excite receptors

Anterior pituitary

Hypothalamus

STRESSORS (internal or external stimuli)

Adrenocorticotropic hormone

Adrenals

STRESS RESPONSE OF BODY TISSUES Elevation of cardiac output Vasomotor changes Lipolysis Glycogenolysis Insulin suppression Increased respiration Enhanced blood coagulation

Corticosteroids Catecholamines

Sympathetic pathways

STRESS RESPONSE OF BODY TISSUES Gluconeogenesis Protein catabolism Inhibition of glucose uptake Suppression of protein synthesis Stabilization of vascular reactivity Immune response suppression

Inhibit

FIG 2.2 Neuroendocrine interactions in response to a stressor. Receptors are excited by stressful stimuli and relay the information to the hypothalamus. The hypothalamus signals the adrenal cortex (by way of the anterior pituitary) and the sympathetic pathways (by way of the autonomic nervous system). The stress response is then mediated by the catecholamines (i.e., epinephrine and norepinephrine) and by the glucocorticoids (predominantly cortisol).

16 UNIT I Pathophysiologic Processes

Stressors vary in their scope, intensity, and duration. A stressor of less intensity can still have a significant impact if it persists for some time. A glass of water held at arm’s length poses little stress initially, but as minutes turn into hours the stress on the body escalates. Even events associated with happiness may serve as stressors—holidays, childbirth, and vacations. Stressors of all types challenge human adaptation.

The identification of specific stressors in isolation provides little insight into today’s complex global society. A given stressor, depending on its type and duration, may have a particular pattern of hormone and neuropeptide release. Researchers have explored innumerable factors that can indirectly increase or decrease the impact of stressors. It is now generally well accepted that individual personal characteristics, as well as the psychological and circumstantial context of the situation, developmental state of the person, and availability of coping resources, allow for a great deal of variation in the way humans perceive and respond to stressors, and thus the type of stress response produced. The activation of both the sympathetic-adrenal-medullary system response and the HPA axis occurs with a wide variety of physical, mental, and psychosocial stressors. The HPA axis with its glucocorticoid response, however, seems to be notably prominent and dysregulated in cases of depression and posttraumatic stress disorder (PTSD), and is also active when a person’s sense of self is negatively evaluated or the person lacks a sense of control. On the other hand, the sympathetic system is par- ticularly active with anxiety and vigilant states. Furthermore, personality characteristics have been found to be associated with variations in cortisol release and sympathetic-adrenal-medullary system activation in the stress response. Indeed, the effect of personality on the stress response differs with the situational context. An individual’s appraisal of a situation and subsequent reaction is influenced by one’s past experiences and conditioning, cultural influences, social expectations, the availability of social support, and a person’s genetic and epigenetic profile and gender.

Beginning in the early 1970s researchers started to examine gender differences related to stress, and recent research has continued to expand what is known about these differences. For example, one study in the 1980s examined the differences in performance and stress responses of men and women under controlled laboratory conditions. When subjected to a stressful task, there was a 50% to 100% increase in epinephrine release in men, whereas there was little, if any, increase noted in women, who were also found to perform as well as or better than their male counterparts. Women did have an elevation in epinephrine release in a more real-life stress situation (i.e., an academic examination), but these elevations remained well below those of men.

Although some researchers consider these stress response differences between men and women, at least in part, to be related to gender- associated roles and psychological factors, other researchers also attribute these variances to the effects of the sex hormones on the stress response. Data from a recent National Health Interview Survey of adults revealed that in every age group, more women than men reported having serious psychological distress. Women are known to have higher prevalence rates of stress and anxiety-related disorders such as depression and PTSD, whereas men show more substance abuse disorders. Estradiol and estrogen may account for some of the gender differences, as the incidence of affective mood disorders appears to become similar for men and women after the age of 55, after menopause. Estradiol may heighten stress reactivity. Accordingly, stressors and traumatic events may have a greater influence if they occur when menstrual cycle estrogen levels are higher for premenopausal women.

To date, data regarding gender differences in physiologic responses to stressors are conflicting, with some researchers reporting no differences and others indicating higher or lower levels of cortisol or ACTH in

the stress abates. If the stressor is adequately addressed and resolved, the organism returns to its steady-state, having reattained allostatic balance. This process described by Selye is clearly a part of the more recently described process of allostasis. However, with the current understanding of allostasis, it is possible that the organism may have to function at a new baseline steady-state for different physiologic variables, either higher or lower than the previous set-points to achieve adaptation. For instance, the normal partial pressure of carbon dioxide (PCO2) in the blood is 35 to 45 mm Hg, and the normal oxygen saturation is greater than 94% in a healthy individual. For someone with chronic obstructive pulmonary disease, a new normal PCO2 value might be 50 to 60 mm Hg and the oxygen saturation may be 88% to 90%, while still maintaining a homeostatically normal serum pH.

Exhaustion Stage Exhaustion occurs when the body is no longer able to effect a return to homeostasis after prolonged exposure to noxious agents. Selye postulated that when energy resources are completely depleted, death occurs because the organism is no longer able to adapt. He speculated that individuals are born with a given amount of adaptation energy. However, when these adaptive energy stores are depleted, no other resource exists to facilitate recovery. Diseases of adaptation such as hypertension and heart disease occur when the body is continuously taxed by stressors. It is now understood that exhaustion and stress-related disease do not necessarily occur because resources are depleted; instead, they can occur because the actual stress response itself, with all its various biological mediators, can be harmful when repeatedly activated.

Concepts related to allostasis help with understanding the damaging effects of stress. The HPA axis, the sympathetic-adrenal-medullary system, and other systems (including the immune system) work to help the person adapt to and defend against stressors. Wear and tear on the body and on the brain occurs when these body systems are chronically overactivated or underactivated in their attempts to support an allostatic return to homeostasis. The accumulation of all the various mediators produced by the systems is damaging to tissues over time. This wear and tear on the body and brain is called allostatic load. Allostatic load is basically due to the typical demands that are part of daily life as well as unpredictable events. However, with chronic, unremitting, or excessive demands, allostatic load can become an overload. This allostatic overload reflects the “cost” to the body’s organs and tissues for an allostatic response that is excessive or ineffectively regulated and unable to deactivate.

Stressors, Gender and Developmental Influences, and Risk Factors Stressors are agents or conditions that are capable of producing stress and endangering homeostasis. They initiate stress response systems to return to a state of allostatic balance. Every day the human organism encounters stressors. These may be external to the individual (e.g., air pollution, radiation, a motor vehicle accident) or internal (e.g., low blood glucose level or a threat to self-esteem). Common general stressors are physical (e.g., extreme hot or cold air temperature), chemical (e.g., auto exhaust), biological (e.g., bacteria and viruses), social (e.g., overcrowding, difficult relationships, information overload), cultural (e.g., behavioral norms), or psychological (e.g., feelings of hopelessness). Stressors of an emotional or mental origin may be present or anticipated, or may involve the recollection of prior traumatic events. Less commonly noted but extremely powerful stressors are psychosocial experiences over which a person may have little or no personal control. Racial and socioeconomic stressors as well as childhood abuse can produce many of the manifestations of stress described in this chapter.

CHAPTER 2 Homeostasis, Allostasis, and Adaptive Responses to Stressors 17

return to their baselines. However, in cases of allostatic overload, pathologies of a physiologic, psychological, or behavioral nature may result.

Catecholamines: Norepinephrine and Epinephrine Cannon identified that the body’s response to threats resulted in the activation of the adrenal medulla and sympathetic nervous system and therefore the release of the catecholamine neurotransmitters. He deemed this the “sympathico-adrenal system” and believed it was ultimately responsible for what he termed the fight-or-flight reaction. The purpose of the fight-or-flight reaction was the maintenance of the physical and psychological integrity of the organism. The catecholamine neurotransmitters—epinephrine and norepinephrine—play integral roles in allostasis.

Release of catecholamines is initiated through the activation of the hypothalamus gland, a collection of nerve centers situated near the third ventricle close to the base of the brain (see Chapter 39). The cerebral cortex and limbic system (including the hippocampus and amygdala, important for memory and emotions) receive information regarding stressors and determine whether or not something is potentially harmful to the organism (i.e., whether it is stressful). They relay the information to the hypothalamus. (It should be noted, though, that the stress response, depending on the type of stressor, may occur to some extent even in comatose and sedated individuals.) In response to these stressors, the hypothalamus prompts the release of norepinephrine from the sympathetic branch of the autonomic nervous system and locus ceruleus (group of neurons in the brainstem pons) and epinephrine and some norepinephrine from the adrenal medulla. Norepinephrine is released by sympathetic neurons directly into the synaptic clefts near the effector organs and tissues. Additionally, preganglionic fibers from the sympathetic nervous system neurons synapse at the adrenal medulla, stimulating the release of epinephrine and, to a lesser extent, norepi- nephrine. The adrenal catecholamines are released into the bloodstream and travel to effector organs and tissues (endocrine). These circulating adrenal catecholamines have essentially the same effects as sympathetic nerve stimulation and are often seen as an extension of the sympathetic nervous system. The responses on the part of the sympathetic nervous system and the adrenal medulla may differ according to the stimulus. During situations such as exposure to cold temperatures the sympathetic nervous system response with norepinephrine production dominates. Emotional distress or acute hypoglycemia, however, causes a greater response from the adrenal medulla, with increased production of epinephrine.

The effects of catecholamines are profound. They affect cardiovascular function, control fluid volume by activating the renin–angiotensin– aldosterone mechanism, have a role in inflammation and immunity, and affect metabolism; and they are associated with attentiveness, arousal, and memory formation in the central nervous system (CNS). Norepi- nephrine is the primary constrictor of smooth muscle in blood vessels. It therefore regulates blood flow through tissues and its distribution through the organs, as well as, importantly, maintenance of blood pressure. It also reduces gastric secretion, inhibits insulin secretion, and innervates the iris and ciliary muscles of the eyes, thereby dilating the pupils and increasing night and far vision. Epinephrine enhances myocardial contractility and increases heart rate and venous return to the heart, thus increasing cardiac output. It additionally relaxes bronchial smooth muscle, thereby dilating the airways to enable better oxygenation. Epinephrine also increases glycogenolysis, the release of glucose from the liver and inhibits insulin secretion, further elevating blood glucose levels. In the brain, the increased blood flow and availability of glucose lead to augmentations in mental attention and alertness. Epinephrine and norepinephrine also exert immune system effects by influencing

men versus women. The responses seem to depend on the types of stressors assessed. For instance, for adult men, higher cortisol levels were found in studies involving cognitive, harassment, mathematical, and verbal stressors and with social stress testing, whereas higher cortisol levels were found in women compared with men in response to a social interaction stressor. Researchers believe very slight differences in brain architecture due to the effects of sex hormones may result in men and women interpreting and responding to stressors with varied approaches.

Developmental stage of life and age also appear to effect the response to stressors. Children exposed to physical and/or psychosocial maltreat- ment have been shown to have smaller cortices in the prefrontal region of the brain, higher cortisol levels, and elevated levels of inflammation in comparison to other children. Many of these changes persist into adulthood. Additionally, infants whose mothers were depressed or anxious during pregnancy displayed higher cortisol levels in response to stressors. These studies demonstrate the vulnerability to stressors of brain development extending from the prenatal period through adolescence.

Risk factors alone are not inherently stressors, but rather conditions or situations that increase the likelihood of encountering or experiencing a stressor. Using a mobile phone to send text messages while driving is a risk factor for having a motor vehicle accident; running in the dark is a risk factor for falling; and inadequate immunization is a risk factor for certain infectious illnesses. Low SES is a risk factor for exposure to lead and air pollutants in the home and neighborhood. Risk factors also include genetic predisposition and epigenetic factors, as well as adverse early life experiences. By being aware of risk factors, it is possible to decrease the probability of exposure to certain stressors and the associated threat to homeostasis.

KEY POINTS • Stress is a real or perceived threat to the balance of homeostasis. The

stress response is designed to restore balance. • Selye’s general adaptation syndrome (GAS) theory reflects the view of a non-

specific physiologic response to stress. It incorporates three stages indicating the changes in the body’s systemic response: alarm, resistance, and exhaustion.

• Stressors are agents or conditions capable of producing stress. • The body’s response to stressors is meant to be helpful, at least initially,

in terms of mobilizing resources to help manage stressors. • Response to a stressor depends on its magnitude and the meaning that the

stressor has for an individual. Perception of the stressfulness of a stressor depends on genetic constitution, gender, past experiences and conditioning, and social and cultural influences. Stressors may be external or internal. They may be physical, chemical, biological, sociocultural, or psychological.

• Individuals may be more vulnerable to the effects of stressors at certain times including developmental stage of life, the availability of resources, and the effects of other previous or concurrent stressors.

• Risk factors are conditions or situations that increase the likelihood of encountering or experiencing a stressor.

NEUROHORMONAL MEDIATORS OF STRESS AND ADAPTATION Numerous hormones and signaling molecules are involved in the daily maintenance of homeostasis through allostatic processes. These mediators are briefly described here, and their roles in allostasis, adaptation, and disease are discussed in later parts of this chapter. A key idea to the understanding of homeostasis is that once the challenges contributing to allostatic load have been resolved, levels of these chemicals should

18 UNIT I Pathophysiologic Processes

The glucocorticoids are so named because of their significant role in glucose metabolism. The primary glucocorticoid, cortisol, is secreted by the adrenal cortex in response to ACTH from the anterior pituitary. Release of ACTH is itself affected by another releasing hormone, CRH, from the hypothalamus. Negative feedback loops help to maintain cortisol level within a normal range. Cortisol binds to receptors on the hypothalamus and anterior pituitary gland to suppress CRH and ACTH release in a negative feedback loop.

The actions of the HPA axis and catecholamines may synergize or antagonize each other. Catecholamines facilitate the release of ACTH, thereby helping to maintain the function of the HPA axis and release of cortisol. Glucocorticoids promote adrenal medulla synthesis of epinephrine through control of the major enzyme phenylethanolamine N-methyltransferase (PNMT). Glucocorticoids also support the actions of the catecholamines in the maintenance of normal blood pressure and cardiac output. In skeletal muscle, catecholamines antagonize the catabolic glucocorticoid effects by impeding the breakdown of somatic protein. Together, the catecholamines and glucocorticoids facilitate the brain’s development of memory, which is especially important when hazardous circumstances have occurred.

The metabolic effects of cortisol are significant. Cortisol affects protein metabolism. It has an anabolic effect leading to increased rates of protein synthesis in the liver. However, it has a catabolic effect in muscle, lymphoid, and adipose tissues and on skin and bone. This protein breakdown produces increased levels of circulating amino acids. The resulting pool of amino acids from catabolized proteins ensures their availability for the liver. Cortisol then stimulates gluconeogenesis in the liver and a sixfold to tenfold increase in the rate of amino acid conversion to ketoacids and glucose. The catabolism of adipose tissue releases free fatty acids and glycerol that also can be used for gluconeogenesis and to create ketoacids for fuel. Gluconeogenesis ensures an adequate supply of glucose for body tissues in general, but nerve cells have priority. Cortisol may act to preserve available glucose for brain nerve cell use by limiting the uptake and oxidation of glucose by other cells in the body. Cortisol also promotes appetite and food-seeking behaviors.

Glucocorticoids are known for their significant role in the control of the immune response. They suppress the acute-phase response to infection and inflammation, helping to curtail overactivity. This is accomplished by inhibiting the production of select immune cytokines (signaling molecules), by increasing the production of other cytokines, and in some cases by directly inhibiting the proliferation and activation of specific immune system cells. At the same time, when the acute stress of tissue injury or infection occurs, the resulting release of glucocorticoids and catecholamines assists the movement of the necessary immune cells to the affected location. However, with prolonged stress and chronic elevation in the levels of glucocorticoids, desensitization and down- regulation (decrease) of glucocorticoid receptors may occur on some immune cells, eventually resulting in fewer antiinflammatory effects over time. In fact, continued stress can even result in proinflammatory effects. Thus the relationship of the immune system to stress is quite multifaceted, and our understanding of it is evolving.

Aldosterone is the primary mineralocorticoid steroid hormone secreted by the adrenal cortex. Stimulation of the sympathetic nervous system activates the renin–angiotensin system, and the release of aldosterone is the final chemical outcome. The specific stressor of fluid volume depletion also activates the release of renin, similarly initiating the renin–angiotensin system. The primary effect of aldosterone, once bound to receptors in the kidneys’ distal tubules and collecting ducts, is reabsorption of sodium and an increase in the excretion of potassium. Because of osmotic force, water tends to follow sodium; therefore enhanced reabsorption of sodium leads to increased extracellular fluid volume and increased blood pressure. Endogenous glucocorticoids have

the production of cytokines by immune and adipose cells. The effects of the catecholamines are summarized briefly in Table 2.2. For more detail, see Chapter 43.

Adrenocortical Steroids: Cortisol and Aldosterone Among the most versatile hormones in the human body, glucocorticoids have regulatory roles in maintaining fluid volume, metabolism, immunity, inflammatory responses, and brain function (Table 2.3). Glucocorticoids are lipid-soluble hormones, allowing them to pass through cell mem- branes to bind with receptors in the cytosol or nucleus and initiate changes in cellular activities. Practically every body tissue has intracellular glucocorticoid receptors. As opposed to the catecholamines, the onset of their effects is slower, but the duration of action is longer.

TABLE 2.2 Brief Summary of Effects of Catecholamines on Tissues and Organs of the Body

Tissue/Organ Catecholamine Effect

Heart Increases rate Increases speed of impulse conduction Increases contractility

Respiratory tract Relaxes bronchial smooth muscle to dilate airway

Vascular smooth muscle Skin, mesenteric bed, kidneys

Constricts to reduce perfusion

Skeletal muscle, lungs, heart Dilates to increase perfusion Peripheral vasculature Constricts to increase blood pressure Gastrointestinal tract Decreases peristalsis

Contracts sphincters Decreases gastric acid secretion

Eyes Contracts radial muscle to dilate iris and pupil

Relaxes ciliary muscle for far vision Liver Glycogenolysis and gluconeogenesis

for increased glucose levels and thus energy

Central nervous system Promotes arousal, attention, and vigilance

TABLE 2.3 Major Effects of Glucocorticoids in the Stress Response Metabolism Catabolism of muscle, fat, lymphoid tissue,

skin, and bone Liver gluconeogenesis Opposes insulin in transport of glucose

into cells Increased appetite

Fluid balance Sodium and water retention Inflammation and infection Suppressed inflammatory response

Increased neutrophil release Decreased new antibody release Decreased T-lymphocyte production and

function Decreased production of eosinophils,

basophils, and monocytes Support catecholamines Increased epinephrine synthesis

Enhanced vasoconstriction

CHAPTER 2 Homeostasis, Allostasis, and Adaptive Responses to Stressors 19

interacts with numerous neurotransmitters in the brain, counteracting the depressive tendencies often noted with glucocorticoids. Testosterone also appears to have antidepressant and antianxiety effects as it elevates mood. Numerous stressful stimuli, such as illness, surgery, strenuous physical exercise, heart failure, and stressful academic programs, result in significant reductions in circulating testosterone levels. In combination with another hormone, vasopressin, testosterone enhances blood pressure and heart rate reactivity and augments the “fight-or-flight” response. In contrast, the hormone oxytocin (whose impact is modulated by estrogen) and the endogenous opioids are thought to produce a calming effect during times of stress, resulting in the notion that women may have a “tend and befriend” response rather than a “fight-or-flight” response in some situations.

Growth Hormone, Prolactin, and Oxytocin Growth hormone (somatotropin) is released from the anterior pituitary gland and affects protein, lipid, and carbohydrate metabolism. It has anabolic effects, increasing protein synthesis and bone and muscle mass growth. It also increases fat mobilization (lipolysis) while decreasing the rate of carbohydrate utilization by peripheral tissues. Growth hormone is normally secreted in a cyclic basal pattern, primarily at night, and changes with developmental stage. Growth hormone secretion is highest during adolescence and then gradually declines during adult- hood. Serum levels of growth hormone also increase acutely after a variety of intensely stressful physical or psychological stimuli, such as strenuous exercise or extreme fear. Growth hormone appears to enhance immune function. However, continued activation of the stress response eventually results in the decreased secretion of growth hormone, accounting for stunted growth in children experiencing prolonged chronic stress.

Prolactin is similar in structure to growth hormone and is secreted from the anterior pituitary gland in response to stress, sexual activity, pregnancy, and suckling (even in men) and breast feeding. It suppresses ovulation. Numerous tissues have receptors for prolactin in addition to the breast, including the kidneys, liver, and adrenal glands. Lym- phocytes also have prolactin receptors, suggesting a role for prolactin in immune regulation. A significant increase in the level of growth hormone or prolactin tends to require more intense stimuli than the stress that increases the concentrations of catecholamines and glucocorticoids.

Oxytocin is produced during childbirth, lactation, and sexual behavior (in both genders) and has been associated with promoting bonding and social attachment. Oxytocin is thought to moderate the stress response and have a calming effect, with reductions in HPA and sympathetic activation and reduced perceived anxiety. In an intriguing study, researchers found that preteenage girls who spoke with their mothers on the phone immediately after a laboratory social stressor had higher levels of urinary oxytocin and lower levels of salivary cortisol than did those who merely texted their mothers. Hearing the mother’s voice appeared important to the release of the oxytocin and buffered the stress response. Oxytocin also may have some analgesic effects. It is synthesized by the hypothalamus and secreted by the posterior pituitary gland and other brain regions. Oxytocin is believed to have stronger effects in females in comparison to males because of the interaction of estrogen and oxytocin.

Through interactions of the primary stress hormones—catecholamines and glucocorticoids—as well as numerous other mediating influences, the allostatic process needed to sustain the human organism is achieved. In some cases, these stress-related hormones have similar and synergistic effects and in others they work in opposition. This state of counterbalanc- ing helps to facilitate allostasis, ideally returning the human organism back toward homeostasis.

a small amount of mineralocorticoid effect, but the greatest effect on circulating volume is through aldosterone. Additionally, angiotensin II, whose formation stimulates aldosterone release, is a potent vasoconstric- tor. This chemical mediator provides support for the catecholamine- induced increase in blood pressure.

Endorphins, Enkephalins, and Immune Cytokines Stress naturally activates the inhibition of pain through the release of small peptides called endorphins and enkephalins. First discovered in 1975, endorphins and enkephalins are endogenous opioids that are produced within the CNS and released in response to stressors, by certain foods (most notably chocolate), by laughter, and from massage or acupuncture. The term endorphin comes from endogenous and morphine. Like the opiate drug morphine, endorphins raise the pain threshold (reduce pain) and produce sedation and euphoria. During acute stress, the endogenous opioids also may attenuate the stress response, especially activation of the SNS by CRH. Some immune cells (B and T lymphocytes, granulocytes, macrophages, and monocytes) also produce several types of endorphins that are released in response to stressors, CRH, antiinflammatory cytokines, and catecholamines. Opioid recep- tors have been identified on immune cells, and when activated they modulate both immune cell proliferation and immune cell activity. On the other hand, in the presence of acute or chronic stress, activated immune cells (mast cells, neutrophils, macrophages, and T lymphocytes) can release proinflammatory cytokines that enhance pain. Pain is a classic manifestation of the inflammatory response (Chapter 9). Thus the central and peripheral nervous systems and the immune system maintain complex patterns of interactions with pain pathways as part of the allostatic mechanism to return to homeostasis.

Another example of the interaction between stress, the nervous system, and the immune system is interleukin-1 (IL-1), one of the cytokines secreted by macrophages and other immune cells. It is capable of affecting the production of CRH by the hypothalamus. Leukocytes are also capable of producing some of the other hormones, such as ACTH, that are involved in the signaling system. Some researchers propose that stressors of relatively short duration (e.g., less than 2 hours) could augment facets of immune function, including the emigration of immune cells from the lymphoid tissues (e.g., the spleen) to the skin and peripheral components of the vascular system. On the other hand, numerous studies over the years have shown that severe and persistent psychological stress can down-regulate or suppress immune functioning through innumerable and elaborate mechanisms. Immune system suppression caused by severe or persistent stress represents a direct link between stress and illness. Expanded understanding of the interrelationships between the nervous, endocrine, and immune systems holds great promise in the identification of new therapeutic interventions.

Sex Hormones: Estrogen, Testosterone, and Dehydroepiandrosterone As noted previously, women and men often have different stress responses, and this may be partially attributable to the influences of the sex hormones and their interactions with the mediators of allostasis. Excessive stress appears, in general, to inhibit female reproduction and affect premenstrual symptoms. Cortisol exerts inhibiting effects on the female reproductive system by suppressing release of gonadotropin-releasing hormone, luteinizing hormone, estradiol, and progesterone; whereas estradiol normally down-regulates glucocorticoid receptor binding in the brain and alters regulatory feedback control. Androgens, such as testosterone and dehydroepiandrosterone (DHEA), also may inhibit the effects of glucocorticoids. Androgens oppose the catabolic effects of glucocorticoids on bone and the impact of glucocorticoids on lymphoid tissues, inflammatory cytokines, and leukocytes. DHEA

20 UNIT I Pathophysiologic Processes

bend without breaking in the face of environmental or psychological perturbations.”

Because allostasis is a process of attaining and maintaining stability through change that leads to a state of adaptation, the terms adaptation and resilience have been intertwined with allostasis. Resilience is the capacity to “adapt to stress and adversity,” thereby preventing the development of disease and mitigating the effects of allostatic load. It means attaining a positive outcome when encountering adversity. Resilience can be affected by multiple factors, some of which include genetics; epigenetic changes resulting from early life exposure to traumatic events; the availability of social support and coping mechanisms; a sense of optimism and control; prior learning; and lifestyle factors such as physical activity (exercise), diet and nutrition, and adequate sleep. Resilience is influenced by the chemical allostatic mediators that promote adaptation such as cortisol, and some neural proteins such as brain- derived neurotrophic factor (BDNF), which may be necessary for brain plasticity.

Maladaptation, a less frequently used term, refers to ineffective, inadequate, or inappropriate change in response to new or altered circumstances. Coping is another term used and is most often seen as a behavioral adaptive response to a stressor. Coping mechanisms are typically culturally based, and consequently vary with the individual within the parameters of what is acceptable to the given culture. The coping behavior is usually dictated by the specific stressor; thus it fluctuates with the circumstances, but individuals typically embrace a specific repertoire of coping behaviors. These behavioral adaptations allow an individual or a group to withstand successfully the stressful experience or the stress response generated by the experience. A coping strategy can be considered effective or functional if it helps resolve either the situation or the feelings. In some cases, such as exercise, mindfulness meditation, and seeking social support, the coping method can promote health. A coping strategy is considered ineffective or dysfunctional if it does not achieve the desired goal. Coping that achieves unintended goals is considered dysfunctional or maladap- tive. Adaptation may result in the adoption of less-than-desirable coping behaviors, such as excessive eating or alcohol consumption, smoking, or other types of substance abuse and avoidance behaviors. Unfortunately, these dysfunctional coping behaviors can ultimately be damaging to overall health. Smoking and overeating contribute to ath- erosclerosis, the underlying pathophysiology of coronary artery disease and a risk factor for hypertension. Excess weight accumulated through overeating is a contributing factor for type 2 diabetes mellitus and metabolic syndrome. Although coping is customarily interpreted as behavioral adaptation only, the terms coping and adapting often are used interchangeably.

Perception and expectations of the stressor can affect its interpretation, and therefore the behavior evoked by it. Perceptions can be related to uncertainty about the meaning of the stressor. Consider the stressor of undue noise. The “bang” of a car backfiring could also be the sound of a gun being fired. Depending on the environment and circumstances, one or the other etiology would be more expected, dictating different adaptive responses. The term distress describes the experience of perceiv- ing an inability to cope with a physiological or psychological stressor. This distress further activates the release of catecholamines from the adrenal gland medulla and glucocorticoids through the HPA axis, escalating levels of circulating mediators, and may exacerbate existing allostatic load and preexisting pathophysiologic conditions. For instance, the person with asthma who is experiencing an episode of acute shortness of breath is likely to become even more short of breath when discovering an inhaler is not readily available.

Adaptation to a stressor can occur in several ways. Loud noise is a known stressor. Yet people who live close to busy airports often reach

ADAPTATION, COPING, AND ILLNESS

Although much has been learned about the dynamic biological systems and human/environmental interactions involved, stress is personal in that individual stress responses change with time and circumstances. Indeed, the effects of stress on each individual are influenced by genet- ics, SES, environmental context, perception, developmental history, prior susceptibilities, preexisting health status, and individual coping abilities. Clearly, the maintenance of homeostasis requires the human organism to routinely initiate allostatic responses to the stressors of daily life, as well as to the less frequent severe assaults on the integrity of the body and the mind, responsible for allostatic load. Systemically, allostasis may be seen as beginning with some degree of the alarm stage (fight-or-flight activation), and ideally moving to an effective resolution through adaptation, ultimately culminating in a return to homeostasis. The prolonged effects of allostatic overload—the long- term wear-and-tear costs of adaptation efforts—provide a conceptual foundation for examining the long-term consequences of stress on health. What Selye called “diseases of adaptation” are the outcomes of allostatic overload.

Adaptation, Coping, and Resilience Adaptation broadly refers to the biopsychosocial process of adjusting physiology, morphology, and behavior in response to new or altered circumstances, internal and external in origin, in the physical and social environment. Related to adaptation is the term resilience. Resilience is the ability to withstand threats to stability and is a measure of the capacity to adapt to challenges. It has been described as the “ability to

KEY POINTS • Modern views of allostatic maintenance of homeostasis in the face of stress

are primarily derived from an understanding of negative feedback, as well as the roles of the sympathetic nervous system catecholamines and the glucocorticoid cortisol.

• The primary role of the sympathetic nervous system (SNS) is appraisal of a stressful stimulus and release of norepinephrine. Norepinephrine released from sympathetic nerve endings increases heart rate and contractility, constricts blood vessels to decrease blood flow to less essential tissues and organs and raise blood pressure, reduces gastrointestinal motility and gastric acid secretion, dilates the pupils, and inhibits insulin secretion.

• Stress stimulates sympathetic activation of the adrenal medulla to release epinephrine. Epinephrine’s actions are similar to norepinephrine and are particularly important for increasing cardiac performance (increased heart rate, contractility, and cardiac output), promoting the release of glucose from the liver, and enhancing bronchodilation.

• Cortisol, from the adrenal cortex, has widespread effects on numerous tissues that are both synergistic and antagonistic with catecholamines and has an antiinflammatory role.

• Aldosterone promotes fluid volume expansion and increases blood pressure.

• Endorphins and enkephalins are released by the CNS in response to painful stressors, leading to decreased perception of pain and increased sedation and euphoria. Immune cells in the periphery also contribute to pain modulation.

• Immune cells respond to the hormones released by the HPA axis and sympathetic nervous system. They also release cytokines that in turn affect the functioning of these stress systems.

• Sex hormones and differential release of growth hormone, prolactin, and oxytocin produce effects on the stress response that may differ between genders.

CHAPTER 2 Homeostasis, Allostasis, and Adaptive Responses to Stressors 21

pathologies. Not only do catecholamines contribute to the development of atherosclerosis and hypertension, they also increase the risk of developing cardiac dysrhythmias and sudden cardiac death, and even stress-induced cardiomyopathy. They increase platelet activity, resulting in clot formation, and elevate serum lipid levels, significant factors in the pathogenesis of myocardial infarction. A growing body of evidence further suggests that inflammation may mediate a link between stress and cardiovascular disease. Stress has been associated with the production of proinflammatory cytokines such as IL-1, IL-6, and tumor necrosis factor (TNF). These cytokines can trigger the production of C-reactive protein (CRP), a cytokine associated with cardiovascular disease.

The field of psychoneuroimmunology has provided substantive evidence of the roles of the stress hormones in the brain. In the central nervous system, specifically the brain, the mediators of adaptation facilitate learning, memory, and neuroendocrine and autonomic regula- tion. This heightened memory, at least in the short term, allows the individual to be more aware of the potential stressor in the future. Chronic overactivity or underactivity, however, may result in atrophy of some nerve cells (especially in the hippocampus), impairing memory, whereas others have been found to hypertrophy (especially in the amygdala) and undergo remodeling, resulting in an increase in fear, anxiety, and other mood disorders. In essence, allostatic overload results in altered and impaired cognitive function. Some evidence suggests that inflammation associated with allostatic overload may play a role in learning and memory impairment. For instance, elevated levels of proinflammatory cytokines, such as IL-1 and IL-6, markers of

a point at which they barely notice the noise of airplanes flying over their homes. They become habituated to the stressor (loud noise). One important way to habituate to a stressor is to manipulate, or “train,” the hypothalamus to react less forcefully to a perceived threat or stressor. Repeatedly ignoring a specific stressor prevents the inappropriate trig- gering of the GAS. The result is a more acceptable level of stress response. Techniques that accomplish this desensitization change the predominant brain waves of the individual from beta to alpha waves, which are slower and more normal. Biofeedback, visualization, and meditation are examples of therapies that use this principle. Practicing these techniques for 20 to 30 minutes daily can enhance the ability to alter how a stressor is perceived and modulate the stress response. These techniques have documented efficacy in enhancing immune function. Desensitization methods have been found to be beneficial for common stress-related conditions, such as migraine headache, chronic back pain, and hypertension.

Allostatic Overload and Illness When adaptation mechanisms are inadequate or the total amount of allostatic load is excessive, overwhelming allostasis capacities, the result is allostatic overload. There are several ways in which allostatic load can accumulate in an individual: (1) repeated exposures to multiple stressors, (2) inability to habituate or adapt to the stressor, (3) unneces- sarily prolonged stress response or stress response that continues after the stressor is removed, and (4) inadequate response to the stressor that causes other stress response mediators to attempt to compensate. Homeostasis, the steady-state that previously existed, cannot be attained. Instead, allostatic overload occurs, and the resulting maladaptation can be reflected in a range of pathophysiologic states that span the traditional boundaries of health care, from psychiatric and endocrine disorders to inflammatory disease.

Hair loss, emotional tension, burnout, mouth sores, insomnia, asthma, heart palpitations, neuromuscular movement disorders (tics), tension headaches, muscle contraction backaches, digestive disorders, and irritable bladder are just a few of the common disorders that can be caused by or worsened by stress. Reproductive disorders such as menstrual irregularity in women and male impotence also have been linked with the effects of allostatic overload. Box 2.2 summarizes some of the physiologic and psychological effects of excessive stress. Fig. 2.3 depicts the multiple body organs and systems in which the effects of insufficient or overactive stress responses may be seen.

The chemical mediators of stress have a strong physiologic basis for the role they play in contributing to illness. Cortisol being released from the adrenal cortex supports Selye’s stage of resistance or adaptation, but may also be accountable for pathologic changes. The same can be said of the catecholamines and the other chemical mediators (e.g., immune cytokines). Because these bloodborne chemicals have such broad effects systemically, the impact of excessive or inadequate amounts is understandably wide reaching. In some cases, the relationships have been well substantiated by research; in others, they are hypothesized based upon knowledge of the effects of these chemicals.

The relationship between excessive catecholamine levels and what historically have been called “stress-related” illnesses has often been associated with cardiovascular pathologies such as hypertension, stroke, and myocardial infarction. Abdominal fat cells are well supplied with cortisol receptors, and excessive secretion of cortisol results in the collection of fat in this area. When this fat is released into the bloodstream, the resulting increase in the levels of circulating free fatty acids plays a role in cardiovascular risk. Additionally, repeated or prolonged elevation of blood pressure, especially in combination with the metabolic effects of elevated cortisol and catecholamine levels, promotes the development of atherosclerosis and, ultimately, many cardiovascular

Physical Indicators Elevated blood pressure Increased muscle tension Elevated pulse rate Increased respiration Sweaty palms Cold extremities (hands and feet) Fatigue Tension headache Upset stomach: nausea, vomiting, diarrhea Change in appetite Change in weight Increased blood catecholamine level Hyperglycemia Restlessness Insomnia

Behavioral and Emotional Indicators Anxiety (nonspecific fears) Depression Increased use of mind-altering substances (e.g., alcohol, chemical substances) Change in eating, sleeping, or activity pattern Mental exhaustion Feelings of inadequacy; loss of self-esteem Increased irritability Loss of motivation Decreased productivity Inability to make good judgments Inability to concentrate Increased absenteeism and illness Increased proneness to accidents

BOX 2.2 Physical and Behavioral Indicators of High Stress

22 UNIT I Pathophysiologic Processes

transport into the cells (insulin resistance), the pathophysiologic basis for type 2 diabetes. Elevated cortisol levels also directly increase insulin resistance. Additionally, obesity is associated with the production of proinflammatory cytokines such as TNF-α, IL-1, and IL-6, which also have been connected to diabetes.

In acute stress, activation of the immune system allows for the coordinated defense of the body from damage. At first, leukocytosis and immune function, including phagocytosis and antibody production, may be enhanced to protect the body from foreign invaders (e.g., bacteria and viruses), but then is followed quickly by immunosuppression. Chronic activation of the stress mediators produces immunosuppression and increases the risk of infection and has been implicated in the development of autoimmune diseases and some cancers. Such overactiva- tion also prolongs existing infections and the development of secondary infections. Research supports the hypothesis that physical and emotional stress and dysfunctional coping mechanisms impair both antibody and T-cell–mediated responses to viruses and antiviral and antibacterial vaccines. Stressors of more than 1 month’s duration have been found to be the greatest predictors of the development of colds. Cumulated evidence, in both human and animal models, supports the premise that stress-induced dysregulation of the cellular and humoral arms of the immune system increases risk of infectious disease. Stress has been found by numerous studies to accelerate the progression of HIV infection.

Immune dysregulation can also include the excessive production of cytokines that promote the inflammatory response. Both physical and psychological stressors have been found to accomplish this, sensitizing the overall inflammatory response so that subsequent activations are markedly increased. Early life stress such as low SES and childhood

inflammation associated with stress, have been linked with memory loss, cognitive decline, and the development of Alzheimer disease. Emerging research indicates that males and females may show different patterns of brain structure remodeling in response to chronic stress. Estrogen may exert neuroprotective effects.

Stress hormones have been found to be elevated and dysregulated in major depressive illness. Increased cortisol secretion, decreased testosterone levels in men and women, and increased levels of growth hormone and proinflammatory cytokines have been documented in major depressive illness. Depression is common with chronic diseases such as fibromyalgia and multiple sclerosis, and the elevated cortisol levels associated with allostatic overload may be significant to the progression of some of the diseases. Another condition, PTSD, also appears to be associated with heightened sympathetic-adrenal-medullary responses as well as alterations in the HPA axis. Evidence suggests cortisol and norepinephrine help promote long-term memory consolidation and retention of traumatic and fearful events; however, administration of beta-blockers such as propranolol that interfere with the effects of norepinephrine has been shown to reduce the incidence of PTSD symptoms in many cases.

Allostatic mediators activate and maintain energy reserves, which are initially meant to be helpful in managing stressors. Nonetheless, obesity (especially abdominal obesity), diabetes, atherosclerosis, metabolic syndrome, osteoporosis and bone demineralization, and other diseases, as well as accelerated aging, are associated with their chronic activation. The food-seeking behavior initiated by cortisol is beneficial in the short term, but when cortisol levels are increased by chronic stress of either a physiologic or a psychological origin, this adaptation gone awry results in obesity. Obesity is a risk factor for decreased effectiveness of glucose

NERVOUS SYSTEM Neuropsychological manifestations

Nervous tic Fatigue

Loss of motivation Anxiety

Overeating Depression

Insomnia

INTEGUMENTARY SYSTEM

Eczema Psoriasis Neurodermatitis Acne Hair loss

GASTROINTESTINAL SYSTEM

Gastritis Irritable bowel syndrome

Diarrhea Nausea and vomiting

Ulcerative colitis

GENITOURINARY SYSTEM

Diuresis Irritable bladder

Sexual dysfunction Menstrual irregularity

CARDIOVASCULAR SYSTEM

Disturbances of heart rate and rhythm Hypertension

Stroke Coronary artery disease

MUSCULOSKELETAL SYSTEM

Tension headache Muscle contraction backache Rheumatoid arthritis Inflammatory diseases of connective tissue

IMMUNE SYSTEM

Immunodeficiency Immunosuppression Autoimmune disease

ENDOCRINE SYSTEM

Hyperglycemia Diabetes mellitus

RESPIRATORY SYSTEM

Increased respiration Asthma Hay fever

FIG 2.3 Effects of allostatic overload on body organs and systems.

CHAPTER 2 Homeostasis, Allostasis, and Adaptive Responses to Stressors 23

and anxiety and several other diseases (e.g., cardiovascular disease, diabetes, and cancer) also have been associated with shortened telomeres. This research suggests a mechanism by which stress may contribute to cell death and disease, because telomere shortening may be connected to some extent to elevated cortisol, catecholamine, and inflammatory cytokine levels produced as part of the stress response. On the other hand, telomerase is an enzyme capable of lengthening telomeres and is inversely related to perceptions of stress. In one study, 30 men and women took part in a 3-month meditation retreat program aimed at reducing psychological distress. By the end of the study period, the participants had significantly higher telomerase activity levels in comparison to wait-list controls. In another study, adherence to com- prehensive lifestyle changes involving stress management, aerobic exercise, nutrition, and social support were associated with greater telomere length at 5 years after study initiation in men with prostate cancer in comparison to a control group. More research is needed to understand the relationships among telomeres, telomerase, stress, stress-related diseases, and coping methods, as well as aging and longevity.

abuse and neglect have been associated with signs of inflammation, including elevated levels of IL-6, TNF-α, and CRP later in adulthood and older age. Inflammation may partially explain the relationship between childhood stress and some later-life illness conditions, including cardiovascular disease, type 2 diabetes, and some forms of cancers. Many other diseases also are associated with chronic inflammation: Alzheimer disease, chronic inflammatory bowel disease, depression, PTSD, osteoporosis, rheumatoid arthritis, asthma, and periodontal disease, to name but a few. Wound healing also is impaired by multiple mediators of stress in excessive amounts.

Epigenetics is emerging as a new area of study, with epigenetic changes providing a link between some types of stressors and disease pathologies. Epigenetics refers to modifications in gene activity that do not entail altering the basic DNA sequence. These modifications may involve chemical tags or markers on the DNA that can turn a gene on or off. Examples of the mechanisms include DNA methylation, histone modification, and microribonucleic acid (miRNA) gene expression regulation. For instance, adverse childhood events have been associated with DNA methylation in adults and consequent production of IL-6. It is possible that epigenetic changes acquired as a result of early life adverse experiences such as famine or poor maternal attachment and care may make the person susceptible later as an adult to respond to stressors in ways that are adaptive in a threatening environment but maladaptive in a more friendly situation. As an example, a person prone to responding to stressors with a heightened sense of vigilance and arousal may find this response helpful in the dangerous situation, but it may lead to anxiety and depression when repeatedly used in a safer environment.

Another new area of stress research attracting attention pertains to telomeres and telomerase. Telomeres are the tail ends of chromosomes that get shaved down with repeated cell division; and thus older cells tend to have shorter telomeres than younger ones. These cells with shortened telomeres are more susceptible to death. Telomeres are both markers and mechanisms of biological aging and may serve as a means of measuring a person’s total accumulated exposure to stressors. Chronic stress related to caregiving, lower SES, and number of childhood adversities has been linked with shorter telomere length. Depression

KEY POINTS • Adaptation, or allostasis, is a network of biopsychosocial processes of

responding to a stressor with the goal of reestablishing homeostasis. Coping mechanisms are usually seen as behavioral adaptations to stress, but are often used interchangeably with adaptation; they can contribute to resilience.

• The wear-and-tear effect of adaptation on the body and mind is the allostatic load. It occurs as mediators produced by the stress response systems accumulate and contribute to tissue damage over time. Allostatic load reflects the cumulative costs of adaptation.

• A number of disorders are thought to be related to excessive stress or inappropriate stress responses—allostatic overload. These are a result of the dysregulation and excessive use of the mechanisms and mediators involved in the stress response.

Homeostasis is the state of balance of the body’s biopsychosocial systems. Stressors evoke a stress response and initiate adaptive efforts, an allostatic process, designed to return to this steady-state. The response to stressors is affected by a wide variety of factors. Recently there has been an increase in knowledge regarding the complex interactions of the HPA axis, the SNS, the immune system, genetics and epigenetics, and the chemical mediators of the stress response.

Excessive or prolonged stress and overactivity or underactivity of associated chemical mediators produce disproportionate responses in the body, a condition of allostatic overload known as stress-induced illness. As humans strive to adapt to the constant changes of modern life, the study of stress and stress-related disease has become vital to public health and contributes to the development of increasingly sophisticated models of health and illness.

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26

3

Cell Structure and Function Jacquelyn L. Banasik and Brianne N. Banasik

UNIT II Cellular Function

K E Y Q U E S T I O N S • What are the major cellular structures and their functions? • How do cells acquire and use energy? • How are substances transported across the cell membrane? • Why is it that some cells can produce action potentials and others

cannot?

• How do cells in a multicellular organism communicate with one another?

• What are the normal mechanisms of cellular growth control?

C H A P T E R O U T L I N E Plasma Membrane, 27

Membrane Structure, 27

Lipid Bilayer, 27

Membrane Proteins, 29

Organization of Cellular Compartments, 30 Cytoskeleton, 30

Nucleus, 30

Endoplasmic Reticulum, 31

Golgi Apparatus, 32

Lysosomes and Peroxisomes, 33

Mitochondria, 34

Cellular Metabolism, 34 Glycolysis, 36

Citric Acid Cycle, 36

Oxidative Phosphorylation, 36

Functions of the Plasma Membrane, 39 Membrane Transport of Macromolecules, 39

Endocytosis and Exocytosis, 39

Membrane Transport of Small Molecules, 40

Active Transport Pumps, 41 Membrane Transport Carriers, 42 Membrane Channel Proteins, 44

Cellular Membrane Potentials, 45

Resting Membrane Potential, 45 Action Potential, 45

Intercellular Communication and Growth, 48 Cell Signaling Strategies, 48

Cell Surface Receptor–Mediated Responses, 49

Intracellular Receptor–Mediated Responses, 53

Regulation of Cellular Growth and Proliferation, 54

http://evolve.elsevier.com/Banasik/pathophysiology/

The cell is the fundamental unit of life. As more diseases are understood on the cellular and molecular levels, it appears that the cell is also the fundamental unit of disease. Detailed knowledge of cellular dysfunction has led to the development of more specific and appropriate prevention and treatment modalities for many disease processes. Thus an understand- ing of cellular mechanisms is essential for health care providers and fundamental to the discussions of pathophysiologic processes presented throughout the remainder of this text.

Cells are complex, membrane-bound units packed with a multitude of chemicals and macromolecules. They are able to replicate and thus form new cells and organisms. The first cells on Earth probably arose about 3.5 billion years ago. Over billions of years, the self-replicating molecules now known as deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) are believed to have evolved by chance association and natural selection. Development of the cell membrane created a closed compartment that provided a selective advantage for the cell and

• Review Questions and Answers • Glossary (with audio pronunciations for selected terms) • Animations

• Case Studies • Key Points Review

CHAPTER 3 Cell Structure and Function 27

regulation of cells. The cell membrane is a sensor of signals and enables the cell to respond and adapt to changes in its environment.

According to the fluid mosaic model first described in the 1960s by Singer and Nicolson, the plasma membrane is a dynamic assembly of lipid and protein molecules. Most of the lipids and proteins move about rapidly in the fluid structure of the membrane. As shown in Fig. 3.2, the lipid molecules are arranged in a double layer, or lipid bilayer, which is highly impermeable to most water-soluble molecules, including ions, glucose, and proteins. A variety of proteins embedded, or “dissolved,” in the lipid bilayer perform most of the membrane’s functions. Some membrane proteins are involved in the transport of specific molecules into and out of the cell; others function as enzymes or respond to external signals; and some serve as structural links that connect the plasma membrane to adjacent cells. The lipid structure of the plasma membrane is similar to the structure of the membrane that surrounds the cell’s organelles (e.g., nucleus, mitochondria, endoplasmic reticulum, Golgi apparatus, lysosomes).

Lipid Bilayer The bilayer structure of all biological membranes is related to the special properties of lipid molecules that cause them to spontaneously assemble into bilayers. The three major types of membrane lipids are cholesterol, phospholipids, and glycolipids. All three have a molecular structure that is amphiphilic; that is, they have a hydrophilic (water-loving) charged or polar end and a hydrophobic (water-fearing) nonpolar end. This amphiphilic nature causes the lipids to form bilayers in aqueous solution.

accomplished the first separation of life (inside) from nonlife (outside). In this protected environment, the early cells continued to evolve and develop. Today, a large number of different cell types exist, but many of the basic biochemical mechanisms of these cells are remarkably similar. Scientists believe that all modern cells, from bacteria to human neurons, evolved from common primordial cells. It is therefore possible to unlock many of the secrets of human cellular physiology by studying easily grown and rapidly proliferating cells, such as yeasts and bacteria.

Much of our knowledge of cell physiology has derived from study of the class of cells known as prokaryotic, which includes bacteria and archaea. Prokaryotic cells are smaller and simpler than eukaryotic cells, having no defined nucleus or cytoplasmic organelles. Fungi, plants, and animals belong to the eukaryotic class of cells, which possess a membrane- bound nucleus and a host of cytoplasmic organelles (Fig. 3.1). In this chapter, the essentials of eukaryotic cell structure, physiology, metabolism, and communication are reviewed.

PLASMA MEMBRANE Membrane Structure All cells are enclosed by a barrier composed primarily of lipid and protein called the plasma membrane (plasmalemma). This cell membrane is a highly selective filter that shields internal cell contents from the external environment. The plasma membrane performs a variety of functions, including transport of nutrients and waste products; generation of membrane potentials; and recognition, communication, and growth

Secretory granule

Golgi apparatus

Plasma membrane

Lysosome

Mitochondrion

Centrioles

Microtubules

Rough endoplasmic reticulum

Smooth endoplasmic reticulum

Nucleus

Nucleolus

Ribosomes

FIG 3.1 Structure of a typical eukaryotic cell showing intracellular organelles.

28 UNIT II Cellular Function

lipids with bent, unsaturated hydrocarbon tails tend to increase fluidity. About 50% of the lipid in eukaryotic cell membranes is cholesterol, which serves to decrease membrane permeability and prevent leakage of small water-soluble molecules. In addition to affecting fluidity by the degree of saturation of tail groups, the phospholipids that inhabit the membrane differ in the size, shape, and charge of the polar head groups. Fig. 3.5 shows the structures of the four most prevalent membrane phospholipids: phosphatidylethanolamine, phosphatidylserine, phos- phatidylcholine, and sphingomyelin. Some membrane-bound proteins require specific phospholipid head groups to function properly. Some lipids—sphingolipids and cholesterol in particular—may bind together transiently to form rafts in the sea of moving lipids. These rafts may surround and help organize membrane proteins into functional units. For example, a membrane receptor and its intracellular target proteins may associate together in a raft to facilitate transfer of information across the membrane.

Glycolipids contain one or more sugar (i.e., carbohydrate) molecules at the polar head region. Glycolipids and glycoproteins are found only in the outer half of the lipid bilayer, with the sugar groups exposed at the cell surface (Fig. 3.6). Membrane glycolipids are involved in cell recognition and cell-to-cell interactions.

A typical phospholipid molecule is shown in Fig. 3.3. The hydrophobic nonpolar tails tend to associate with other hydrophobic nonpolar tail groups to avoid association with polar water molecules. The hydrophilic polar head groups preferentially interact with the surrounding aqueous environment. A bilayer, with tails sandwiched in the middle, allows both portions of the lipid molecules to be chemically “satisfied.” In addition, the lipid bilayers tend to close on themselves, forming sealed, spherical compartments (Fig. 3.4). If the membrane is punctured or torn, it will spontaneously reseal itself to eliminate contact of the hydrophobic tails with water.

For the most part, individual lipid and protein molecules can diffuse freely and rapidly within the plane of the bilayer. The degree of membrane fluidity depends on the lipid composition. Saturated lipids have straight tails that can pack together and tend to stiffen the membrane, whereas

FIG 3.2 Section of the cell membrane showing the lipid bilayer structure and integral membrane proteins.

Hydrophilic head

Hydrophobic tail

H H H

H HC C C

O

O O

C O

O

CH2

CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH3

CH2 CH3

CH3 CH3

P

N+

OO–

C O

CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH2 CH3

FIG 3.3 Schematic drawing of a typical membrane phospholipid molecule showing the amphiphilic nature of the structure.

Water

Water

FIG 3.4 The amphiphilic nature of membrane lipids results in bilayer structures that tend to form spheres.

CHAPTER 3 Cell Structure and Function 29

associate with polar lipid head groups. The three-dimensional structure of many membrane proteins is complex, with numerous twists and turns through the lipid bilayer (Fig. 3.8).

The type of membrane proteins in a particular cell depends on the cell’s primary functions. For example, a kidney tubule cell has a large proportion of transmembrane proteins, which are needed to perform the kidney’s function of electrolyte and nutrient reabsorption. In contrast, the human red blood cell (RBC) contains mainly peripheral proteins attached to the inner surface of the membrane. One of these proteins, spectrin, has a long, thin, flexible, rodlike shape that forms a supportive meshwork, or cytoskeleton, for the cell. It is this cytoskeleton that enables the RBC to withstand the membrane stress of being forced through small capillaries.

Although proteins and lipids are generally free to move within the plane of the cell membrane, many cells are able to confine certain proteins to specific areas. Using the example of the kidney tubule cell again, it is important for the cell to keep transport proteins on its luminal side to reabsorb filtered molecules (Fig. 3.9). This segregation of particular proteins is accomplished primarily by intercellular con- nections called tight junctions, which connect neighboring cells and function like a fence to confine proteins to an area of the membrane. Membrane proteins also can be immobilized by tethering them to cytoskeleton or extracellular matrix structures.

Membrane Proteins Approximately 50% of the mass of a typical cell membrane is composed of protein. The specific types of membrane proteins vary according to cell type and environmental conditions. Some membrane proteins, called transmembrane proteins, extend across the membrane bilayer and are in contact with both the extracellular and the intracellular fluids. Transmembrane proteins serve a variety of functions, including transport of charged and polar molecules into and out of cells and transduction of extracellular signals into intracellular messages. Other peripheral membrane proteins are less tightly anchored to the membrane. The common structural orientations of membrane proteins are shown in Fig. 3.7. The amino acid structure of membrane proteins determines the way they are arranged in the membrane. Nonpolar amino acids tend to inhabit the hydrophobic middle of the membrane, whereas charged and polar amino acids protrude into the aqueous fluid or

O

P O

+NH3 +NH3

CH2

CH2

CH2

O–

CH2 CH

O

C

O

O C

O

O

F a tt y

a ci

d

F a tt y

a ci

d

O

C

P O

CH2

CH2

O–

COO–

CH2 CH

O

C

O

H

O C

O

O

F a tt y

a ci

d

F a tt y

a ci

d

O

P O

CH2

CH2

CH2

O–

CH2 CH

O

C

O

O C

O

O

F a tt y

a ci

d

F a tt y

a ci

d

CH2 CH

OH

CH

CH

CH

C

NH

O

F a tt y

ch a in

F a tt y

a ci

d t a il

O

P O

CH2

O–

O

Phosphatidylethanolamine Phosphatidylcholine Phosphatidylserine Sphingomyelin

CH3 CH3 N

CH3

+

CH2

CH3 CH3 N

CH3

+

FIG 3.5 Chemical structures of the four most common membrane phospholipids.

Extracellular fluid

Intracellular fluid

Sugar molecules

Lipid bilayer

Glycoproteins

FIG 3.6 Portion of the cell membrane showing orientation of membrane glycoproteins toward the outer surface of the cell.

KEY POINTS • The plasma membrane is composed of a lipid bilayer that is impermeable

to most water-soluble molecules, including ions, glucose, and amino acids, but is permeable to lipid-soluble substances, such as oxygen and steroid hormones.

• Proteins embedded in the lipid bilayer execute most of the membrane’s functions, including transport and signal transduction.

30 UNIT II Cellular Function

three main groups of cytoskeletal filaments just described, a large number of accessory proteins are essential for cytoskeletal function. For example, the accessory protein myosin is needed to bind with actin to achieve motor functions. Different accessory proteins are present in different cell types.

Nucleus The largest cytoplasmic organelle is the nucleus, which contains the genetic information for the cell in the form of DNA. The human genome contains nearly 20,000 genes that code for proteins, representing less than 1.3% of the total DNA structure composed of more than 6 billion base pairs. The nuclear contents are enclosed and protected by the nuclear envelope, which consists of two concentric membranes. The inner membrane forms an unbroken sphere around the DNA and contains protein-binding sites that help to organize the chromosomes inside. The outer nuclear membrane is continuous with the endoplasmic reticulum (ER) (see next section) and closely resembles it in structure and function (Fig. 3.11). The nucleus contains many proteins that help mediate its functions of genetic control and inheritance. These proteins, including histones, polymerases, and regulatory proteins, are manufac- tured in the cytosol and transported to the nucleus through holes in the membrane called nuclear pores. The nuclear pores are selective about which molecules are allowed access to the nuclear compartment, and in this way they protect the genetic material from enzymes and other molecules in the cytoplasm. The nuclear pores also mediate the export of products such as RNA and ribosomes that are synthesized in the nucleus but function in the cytosol. Ribosomes are manufactured in a specialized portion of the nucleus called the nucleolus. Nuclear pores are complexes of proteins that span across both the inner and the outer nuclear membrane, creating a pathway between the cytoplasm and the nuclear lamina (see Fig. 3.11).

A major function of the nucleus is to protect and preserve genetic information so that it can be replicated exactly and passed on during cell division. However, the nucleus is continuously functioning even when the cell is not actively dividing. The nuclear DNA controls the production of cellular enzymes, membrane receptors, structural proteins,

ORGANIZATION OF CELLULAR COMPARTMENTS Cytoskeleton Eukaryotic cells have a variety of internal compartments, or organelles, that are membrane bound and carry out distinct cellular functions. The cell’s organelles are not free to float around haphazardly in the cytoplasmic “soup”; rather, they are elaborately organized by a protein network called the cytoskeleton (Fig. 3.10). The cytoskeleton maintains the cell’s shape, allows cell movement, and directs the trafficking of substances within the cell. Three principal types of protein filaments make up the cytoskeleton: actin filaments, microtubules, and intermediate filaments.

All three types of filaments consist of small proteins that can assemble (polymerize) into filaments of varying length. The filament structures are dynamic and can be rapidly disassembled and reassembled according to the changing needs of the cell. Actin filaments play a pivotal role in cell movement. As one might expect, muscle cells are packed with actin filaments, which allow the cell to perform its primary function of contraction. However, nonmuscle cells also possess actin filaments that are important for complex movements of the cell membrane, such as cell crawling and phagocytosis. Such movements of the cell membrane are mediated by dense networks of actin filaments that cluster just beneath the plasma membrane and interact with specific proteins embedded in it. Actin and some of the other cytoskeletal proteins make specific contacts with and through the plasma membrane and are involved in information transfer from the extracellular environment to signaling cascades within the cell.

Organization of the cytoplasm and its organelles is achieved primarily by microtubules. In animal cells, microtubules originate at the cell center, or centrosome, near the nucleus and radiate out toward the cell perimeter in fine lacelike threads. Microtubules guide the orderly transport of organelles and vesicles in the cytoplasm, as well as the equal distribution of chromosomes during cell division. Intermediate filaments, so named because their size is between that of microtubules and actin filaments, are strong, ropelike, fibrous proteins. A variety of intermediate filaments that differ from tissue to tissue have been identified. In addition to the

Extracellular fluid

Intracellular fluid

C

D

B

P P

A

FIG 3.7 Structural orientation of some proteins in the cell membrane. A, Membrane-associated protein with noncovalent attachment to plasma lipids. B, Membrane protein with noncovalent attachment to another membrane protein. C, Transmembrane protein extending through the lipid bilayer. D, Covalently attached peripheral membrane protein.

CHAPTER 3 Cell Structure and Function 31

gather the chromosomes and then fuse together to form a new nuclear membrane. Nuclear proteins and pore structures are then recruited back to their normal nuclear locations.

Endoplasmic Reticulum The ER is a membrane network that extends throughout the cytoplasm and is present in all eukaryotic cells (Fig. 3.12). The ER is thought to have a single continuous membrane that separates the lumen of the ER from the cytosol. The ER plays a central role in the synthesis of membrane components, including proteins and lipids, for the plasma membrane and cellular organelles, as well as in the synthesis of products to be secreted from the cell. The ER is divided into rough and smooth types based on its appearance under the electron microscope. The rough ER is coated with ribosomes along its outer surface. Ribosomes are complexes of protein and RNA that are formed in the nucleus and transported to the cytoplasm. Their primary function is the synthesis of proteins (see Chapter 5). Depending on the destination of the protein to be created, ribosomes may float free in the cytosol or may bind to the ER membrane. Proteins synthesized by free-floating ribosomes are released within the cytosol of the cell. Proteins to be transported into the ER have a special sequence of amino acids that directs the ribosome responsible for its synthesis to the ER membrane. Special proteins called signal recognition particles bind to the leading sequence of the protein and then bind to a receptor on the ER membrane. As the ribosome adds amino acids to the growing protein chain, it is pushed into the lumen of the ER through a pore in the ER membrane called a translocon. After being processed in the ER and Golgi apparatus, the protein is

FIG 3.8 Transmembrane proteins have complex folded structures, often with several twists and turns through the membrane. Cytochrome C oxidase. (From The European Bioinformatics Institute. http://www.ebi.ac.uk/. March 20, 2017.)

Kidney tubule

Transport proteins

Tubule epithelial cells

Tight junctions

N N

N N N

FIG 3.9 Transport proteins may be confined to a particular portion of the cell membrane by tight junctions. Segregation of transport proteins is important for the absorptive functions of the kidney epithelial cells. N, Nucleus.

and other proteins that define the cell’s type and behavior. (The structure and function of DNA are discussed in Chapter 5.)

During mitosis, the complex structure of the nuclear membrane is retracted into the endoplasmic reticulum membrane. After cell division is complete, pieces of nuclear membrane reemerge to surround and

32 UNIT II Cellular Function

Golgi Apparatus The Golgi apparatus, or Golgi complex, is composed of a stack of smooth membrane-bound compartments resembling a stack of hollow plates or pita breads (see Fig. 3.12). These compartments, or cisternae, are organized in a series of at least three processing compartments. The first compartment (cis face) lies next to the ER and receives newly synthesized proteins and lipids by way of ER transport vesicles. These transport vesicles are outgrowths that bud off from the ER membrane and diffuse to the Golgi, where they bind and become part of the Golgi apparatus membrane. The proteins and lipids then move through the middle compartment (medial) to the final compartment (trans face), where they depart for their final destination. As the lipid and protein molecules pass through the sequence of Golgi compartments, they are modified by enzymes that attach or rearrange carbohydrate molecules. After specific arrangement of these carbohydrates has occurred, the lipids and proteins are packaged into Golgi transport vesicles (secretory vesicles). The particular configuration of carbohydrate molecules on the lipid or protein is believed to serve as an “address label,” direct- ing them to the correct destination within the cell. Golgi vesicles transport their contents primarily to the plasma membrane and to lysosomes.

eventually transported to the appropriate organelle or secreted at the cell surface. Free-floating and rough ER ribosomes are identical and interchangeable; their location depends on the amino acid structure of the protein they are producing at the time.

Regions of ER that lack ribosomes are called smooth ER. The smooth ER is involved in lipid metabolism. Most cells have very little smooth ER, but cells specializing in the production of steroid hormones or lipoproteins may have significant amounts of smooth ER. For example, the hepatocyte (liver cell) has abundant smooth ER–containing enzymes (P450) responsible for the manufacture of lipoproteins as well as the detoxification of harmful lipid-soluble compounds, such as alcohol. The cellular smooth ER can double in surface area within a few days if large quantities of drugs or toxins enter the circulation. Cells in the adrenal cortex and gonads that produce steroid hormones also have abundant smooth ER. In addition to synthetic functions, the ER sequesters calcium ions by pumping them from the cytoplasm. In response to specific signals, the ER releases calcium ions as part of important second-messenger cascades. Muscle cells have extensive smooth ER (sarcoplasmic reticulum) dedicated to the sequestration of calcium. When the cell is stimulated, the sarcoplasmic reticulum releases the calcium ions needed to accomplish muscle contraction.

A

MICROFILAMENT

7 nm

Protein molecule

B

10 nm

Protein molecule

INTERMEDIATE FILAMENT

C

Protein subunit

25 nm

MICROTUBULE

FIG 3.10 Schematic and micrographs of three major types of cytoskeletal proteins. A, Microfilaments shown are composed of actin proteins. B, Intermediate filaments are a large group of various types of proteins. C, Microtubules. (From Patton KT, Thibodeau GA: Anatomy & physiology, ed 9, St. Louis, 2016, Mosby, p. 89. Micrographs from Pollard T, Earnshaw W: Cell biology, revised reprint, international edition, Philadelphia, 2004, Saunders.)

CHAPTER 3 Cell Structure and Function 33

fusing with a lysosome. The final products of lysosomal digestion are simple molecules, such as amino acids, fatty acids, and carbohydrates, which can be used by the cell or secreted as cellular waste at the cell surface.

Discovery of the mechanism for sorting and transport of lysosomal enzymes was aided by studying patients suffering from lysosomal storage diseases. Patients with I-cell (inclusion cell) disease, for example, accumulate large amounts of debris in lysosomes, which appear as spots, or “inclusions,” in the cells. These lysosomes lack nearly all of the hydrolases normally present and thus are unable to perform lysosomal digestion. However, all the hydrolases missing from the lysosomes can be found in the patient’s bloodstream. The abnormality results from “mis-sorting” by the Golgi apparatus, which erroneously packages the enzymes for extracellular secretion rather than sending them to the lysosomes. Studies of this rare genetic disease resulted in the discovery that all lysosomal enzymes have a common marker, mannose- 6-phosphate, which normally helps target the enzymes to the lysosomes. Persons with I-cell disease lack the enzyme needed for configuring this marker.

Peroxisomes (microbodies), like lysosomes, are membrane-bound bags of enzymes that perform degradative functions. They are particularly important in liver and kidney cells, where they detoxify various

Lysosomes and Peroxisomes Transport of Golgi vesicles to the membrane-bound bags of digestive enzymes known as lysosomes has been well described and provides a model for Golgi sorting and transport to other destinations. Lysosomes are filled with more than 40 different acid hydrolases, which are capable of digesting organic molecules, including proteins, nucleotides, fats, and carbohydrates. Lysosomes obtain the materials they digest from three main pathways. The first is the pathway used to digest products absorbed by endocytosis. In this pathway, endocytotic vesicles bud off from the plasma membrane to fuse with endosomes. Endosomes mature into lysosomes as the Golgi delivers lysosomal enzymes to them; the pH inside the lysosome acidifies, and active digestion occurs. The second pathway is autophagy, whereby damaged and obsolete parts of the cell itself are destroyed. Unwanted cellular structures are enclosed by a membrane from the ER, which then fuses with the lysosome, leading to autodigestion of the cellular components. Autophagy also may occur during cell starvation or disuse, leading to a process called atrophy, in which the cells become smaller and more energy efficient. The third pathway providing materials to the lysosomes is present only in specialized phagocytic cells. White blood cells (WBCs), for example, are capable of ingesting large particles, which then form a phagosome capable of

Cytoplasmic filament

Cytoplasmic ring

Spoke ring

B

A

Outer membrane

Inner membrane

Lumen Nuclear ring

Basket filament

Terminal ring

Nuclear basket

Nuclear envelope

Nucleus

Nucleolus

Outer nuclear membrane

Endoplasmic reticulum

Nuclear pores

Inner nuclear membrane

Nuclear envelope

FIG 3.11 A, Structure of the double-membrane envelope that surrounds the cell nucleus. B, Detail of a nuclear pore.

34 UNIT II Cellular Function

important membrane-bound enzymes of the respiratory chain. These enzymes are essential to the process of oxidative phosphorylation, which generates most of the cell’s adenosine triphosphate (ATP). The outer membrane contains numerous porin transport proteins forming large aqueous channels that make the membrane porous, like a sieve. Fairly large molecules, including proteins up to 5000 daltons, can pass freely through the outer membrane such that the space between the outer and inner membranes is chemically similar to the cytosol. However, the inner membrane is quite impermeable, even to small molecules and ions. Specific protein transporters are required to shuttle the necessary molecules across the inner mitochondrial membrane.

Mitochondria are believed to have originated as bacteria that were engulfed by larger cells but that still retain some of their own DNA. Mitochondrial DNA codes for 22 transfer RNA molecules, 2 ribosomal RNAs that form mitochondrial ribosomes, and 13 proteins. During evolution the majority of mitochondrial genes were transferred to locations within the nuclear genome. Thus only a few of the mitochon- drial enzymes are produced from DNA located in the mitochondria; the majority are transcribed from nuclear DNA. Nuclear genes are translated into protein in the cytoplasm and then transported to the mitochondria, whereas mitochondrial gene–derived proteins are made within the mitochondria. Several rare disorders are associated with mitochondrial gene defects (see Chapter 6). The number and location of mitochondria differ according to cell type and function. Cells with high energy needs, such as cardiac or skeletal muscle, have many mitochondria. These mitochondria may pack between adjacent muscle fibrils, such that ATP is delivered directly to the areas of unusually high energy consumption. Mitochondria undergo fission to produce more mitochondria in the cell. The details of mitochondrial energy conversion are discussed in the next section. Mitochondria also have an important role in programmed cell death, called apoptosis, which is discussed in Chapter 4.

substances, such as alcohol. In contrast to lysosomes, which contain hydrolase enzymes, peroxisomes contain oxidative enzymes. These enzymes use molecular oxygen to break down organic substances by an oxidative reaction that produces hydrogen peroxide. The hydrogen peroxide is then used by another enzyme (catalase) to degrade other organic molecules, including formaldehyde and alcohol. Catalase also prevents accumulation of excess hydrogen peroxide in the cell by convert- ing it to water and oxygen. Peroxisomes also oxidize fatty acids (β oxidation) to produce acetyl coenzyme A (acetyl CoA) that is used in cellular metabolism. Unlike lysosomes, which acquire their enzymes from Golgi vesicles, peroxisomes import enzymes directly from the cytoplasm.

Mitochondria The mitochondria have been aptly called the “powerhouses of the cell” because they convert energy to forms that can be used to drive cellular reactions. A distinct feature of mitochondria is the large amount of membrane they contain. Each mitochondrion is bound by two specialized membranes. The inner membrane forms an enclosed space, called the matrix, which contains a concentrated mix of mitochondrial enzymes. The highly convoluted structure of the inner membrane with its numer- ous folds, called cristae (Fig. 3.13), provides a large surface area for the

Cis (entry) face

Trans (exit) face

Cisternae

Ribosomes

GOLGI APPARATUS

ENDOPLASMIC RETICULUM

PLASMA MEMBRANE

CYTOSOL

Transport vesicles

Nuclear envelope

Secretory vesicles

NUCLEUS

FIG 3.12 Schematic drawing of the endoplasmic reticulum and its relationship to the Golgi apparatus and nuclear envelope. KEY POINTS

• The cytoskeleton is made up of actin, microtubules, and intermediate filaments. These proteins regulate cell shape, movement, and the trafficking of intracel- lular molecules.

• The nucleus contains the genomic DNA. These nuclear genes code for the synthesis of proteins. There are nearly 20,000 protein-coding genes in the human genome.

• The endoplasmic reticulum (ER) and the Golgi apparatus function together to synthesize proteins and lipids for transport to lysosomes or to the plasma membrane.

• Lysosomes and peroxisomes are membrane-bound bags of digestive enzymes that degrade intracellular debris.

• Mitochondria contain enzymes necessary for oxidative phosphorylation to produce adenosine triphosphate (ATP). Mitochondria have their own small number of genes that code for some of the mitochondrial proteins.

CELLULAR METABOLISM All living cells must continually perform essential cellular functions such as movement, ion transport, and synthesis of macromolecules. Many of these cellular activities are energetically unfavorable (i.e., they are unlikely to occur spontaneously). Unfavorable reactions can be driven by linking them to an energy source such as ATP, which is a molecule that contains high-energy phosphate bonds. In normal cells where the ATP concentration is high, approximately 11 to 13 kcal of

CHAPTER 3 Cell Structure and Function 35

A

B

H+ H + H+

H+

H+

H+

H+

H2O

ATP ATP ADP

NAD+

NADH

Pi +

O2

CO2

Pyruvate

Fatty acids

e-

Acetyl CoA

Citric acid cycle

Matrix

Outer membrane

Inner membrane

ATP synthase

Electron transport chain

FIG 3.13 Electron micrograph (A) and schematic drawing (B) of the mitochondrial structure. The highly convoluted inner membrane provides a large surface area for membrane-bound metabolic enzymes. (A, From Alberts B et al, editors: Molecular biology of the cell, ed 6, New York, 2015, Garland Science, p 26. Micrograph courtesy Daniel S. Friend. All rights reserved. Used under license from The American Society for Cell Biology.)

36 UNIT II Cellular Function

mitochondria, such as RBCs, must rely totally on glycolysis for ATP production.

Citric Acid Cycle For most cells, glycolysis is only a prelude to the third stage of catabolism, which takes place in the mitochondria and results in the complete oxidation of glucose to its final end products: CO2 and H2O. The third stage begins with the citric acid cycle (also called the Krebs cycle or the tricarboxylic acid cycle) and ends with the production of ATP by oxidative phosphorylation. The purpose of the citric acid cycle is to break, by oxidation, the C–C and C–H bonds of the compounds produced in the second stage of catabolism. Pyruvate and fatty acids enter the mitochondrial matrix, where they are converted to acetyl CoA (Fig. 3.15). The pyruvate dehydrogenase complex cleaves pyruvate to form one CO2, one NADH, and one acetyl CoA molecule. Fatty acids are cleaved by a process called β oxidation to form one NADH and one reduced flavin adenine dinucleotide (FADH2, another type of electron carrier). No CO2 is produced by β oxidation of fatty acids. Patients who have difficulty excreting CO2 because of respiratory disease are sometimes given a high-fat, low-carbohydrate diet to take advantage of the lower CO2 production that accompanies fat metabolism.

In the first reaction of the citric acid cycle, the two-carbon acetyl group is transferred from coenzyme A to a four-carbon oxaloacetate molecule. This results in the formation of the six-carbon molecule citrate for which the cycle is named. In a series of enzymatic oxidations, carbon atoms are cleaved off in the form of CO2 (Fig. 3.16); this CO2 is free to diffuse from the cell and be excreted by the lungs as a waste product. Two carbon atoms are removed to form two CO2 molecules for each complete turn of the cycle. The extra oxygen molecules needed to create CO2 are provided by the surrounding H2O; therefore the citric acid cycle does not require molecular oxygen from respiration. However, the cycle will cease to function in the absence of oxygen because the carrier molecules, NADH and FADH2, cannot unload their electrons onto the electron transport chain (which does require oxygen) and thus are unavailable to accept electrons from the citric acid cycle.

Although the citric acid cycle directly produces only one ATP molecule (in the form of guanosine triphosphate [GTP]) per cycle, it captures a great deal of energy in the form of activated hydride ions (H−). These high-energy ions combine with larger carrier molecules, which transport them to the electron transport chain in the mitochondrial membrane. Two important carrier molecules are nicotinamide adenine dinucleotide (NAD+), which becomes NADH when reduced by H−, and flavin adenine dinucleotide (FAD), which becomes FADH2 when reduced by H−. The energy carried by these molecules is ultimately used to produce ATP through a process called oxidative phosphorylation. One glucose molecule provides for two turns of the cycle and produces a net of two GTP, four CO2, two FADH2 and six NADH.

Oxidative Phosphorylation Oxidative phosphorylation follows the processes of glycolysis and the citric acid cycle and results in the formation of ATP by the reaction of adenosine diphosphate (ADP) and inorganic phosphate (Pi): ADP + Pi → ATP. The energy to drive this unfavorable reaction is provided by the high-energy hydride ions (H−) derived from the citric acid cycle. This energy is not used to form ATP directly; a series of energy transfers through reduction-oxidation (redox) reactions is required. In eukaryotic cells, this series of energy transfers occurs along the electron transport chain on the inner mitochondrial membrane. The transport chain consists of three major enzyme complexes and two mobile electron carriers that shuttle electrons between the protein complexes

energy per mole of ATP is liberated when one of the phosphate bonds is hydrolyzed (broken with the aid of water) in a chemical reaction. A variety of enzymes in the cell are able to capture the energy released from ATP hydrolysis and use it to break or make other chemical bonds. In this way, ATP serves as the “energy currency” of the cell. A specific amount of ATP is “spent” to “buy” a specific amount of work. Most cells contain only a small amount of ATP, sufficient to maintain cellular activities for just a few minutes. Because ATP cannot cross the plasma membrane, each cell must continuously synthesize its own ATP to meet its energy needs; ATP cannot be “borrowed” from other cells or “banked” in any significant quantity within a cell. It must be synthesized continually from the breakdown of glycogen and fat to meet the cell’s energy needs.

An average adult has enough glycogen stores (primarily in liver and muscle) to supply about 1 day’s needs, but enough fat to last for a month or more. After a meal, the excess glucose entering the cells is used to replenish glycogen stores or to synthesize fats for later use. Fat is stored primarily in adipose tissue and is released into the bloodstream for other cells to use when needed. When cellular glucose levels fall, glycogen and fats are broken down to provide glucose and fatty acyl molecules, respectively, which are ultimately metabolized to provide ATP. During starvation, body proteins can also be used for energy production by a process called gluconeogenesis.

Cellular metabolism is the biochemical process whereby foodstuffs are used to provide cellular energy and biomolecules. Cellular metabolism includes two separate and opposite phases: anabolism and catabolism. Anabolism refers to energy-using metabolic processes or pathways that result in the synthesis of complex molecules such as fats. Catabolism refers to the energy-releasing breakdown of nutrient sources such as glucose to provide ATP to the cell. Both of these processes require a long, complex series of enzymatic steps. The catabolic processes of cellular energy production are briefly discussed in the following sections. (See Chapter 42 for a detailed discussion of metabolism.)

Glycolysis The catabolic process of energy production begins with the intestinal digestion of foodstuffs into small molecules: proteins into amino acids, polysaccharides into simple sugars (monosaccharides), and fats into fatty acids and glycerol. The second stage of catabolism occurs in the cytosol of the cell, where glucose molecules are further degraded by glycolysis into pyruvate (compounds with three carbon atoms). Glycolysis involves 10 enzymatic steps to break the six-carbon glucose molecule into a pair of three-carbon pyruvate molecules (Fig. 3.14). Glycolysis requires the use of two ATP molecules in the early stages but produces four ATP molecules in the later steps, for a net gain of two ATP molecules per glucose molecule. The production of ATP through glycolysis is relatively inefficient, and the pyruvate end products still contain substantial chemical energy that can be released by further catabolism in stage 3. However, glycolysis is an important provider of ATP under anaerobic conditions because oxygen is not required. Thus ATP production by glycolysis becomes important during conditions of reduced cellular oxygenation, which may accompany respiratory and cardiovascular disorders. The pyruvate that accumulates during prolonged anaerobic conditions is converted to lactate and excreted from the cell into the bloodstream. Lactic acidosis is a dangerous condi- tion that may result from excessive lactate production attributable to severe or prolonged lack of oxygen (see Chapter 20). In addition to the two molecules of ATP and pyruvate, each glucose molecule produces two reduced nicotinamide adenine dinucleotide (NADH) molecules, which contain high-energy electrons that are transferred to the elec- tron transport chain in the mitochondria. Cells that do not contain

CHAPTER 3 Cell Structure and Function 37

ATP

ATP

NADH

ATP

ATP

NADH

ATP

ATP

OH2C CH2O PP O

HO

OH

CH2OH

HO OH

OH

OH

STEP 1

STEP 2

STEP 3

STEP 4

STEP 5

O

CH2O

CHOH

CHO

P CH2O

CHOH

CHO

P

STEP 6

STEP 7

STEP 8

STEP 9

STEP 10

CH3

COO�

C O

CH3

COO�

C O

Energy investment to be recouped later

Energy generation

Cleavage of six-carbon sugar to two three-carbon sugars

Two molecules of glyceraldehyde

3-phosphate

Fructose 1,6- bisphosphate

One molecule of glucose

Two molecules of pyruvate

FIG 3.14 Ten enzymatic steps are required in glycolysis to break glucose into two 3-carbon pyruvate molecules. A net gain of two ATP molecules is achieved. (From Alberts B et al, editors: Molecular biology of the cell, ed 6, New York, 2015, Garland Science, p 26. Micrograph courtesy Daniel S. Friend. All rights reserved. Used under license from The American Society for Cell Biology.)

38 UNIT II Cellular Function

(Fig. 3.17). Respiratory chain proteins contain metal ions (iron, copper) that facilitate the transfer of electrons. The hydrogen molecules and their associated electrons are transported to the electron transport chain by the carrier molecules NADH and FADH2. The path of electron flow is NADH → NADH dehydrogenase complex → ubiquinone → b-c1 complex → cytochrome c → cytochrome oxidase complex. With each redox reaction the electrons pass from one complex to the next, and the free energy that is released is used to pump hydrogen ions (H+) out of the mitochondrial matrix. At the very end of the transport chain, low-energy electrons are finally transferred to O2 to form H2O. Oxidative phosphorylation is called aerobic because of this oxygen-requiring step. The last enzyme in the chain, cytochrome oxidase, collects four electrons and then transfers all four at once to a molecule of O2 to create two water molecules. If electrons are not transferred to oxygen in the correct ratio, then oxygen free radicals may be produced and damage the cell. Free radical generation is discussed in Chapter 4.

Thus far, little ATP synthesis has been accomplished. However, the enzymes of the transport chain have harnessed energy from the trans- ported electrons in the form of a proton (H+) gradient. Finally, the proton gradient is used to power the synthesis of ATP. A special enzyme in the inner mitochondrial membrane (ATP synthase) allows protons

S CoAC

CH3

O

Acetyl group

S

FIG 3.15 Space-filling model of acetyl CoA.

NAD+

NADH and H+

NADH and H+

NAD+

HC

CH2

COO–

COO–

COO–

HC OH

C

CH2

CH2

COO–

COO–

COO–

HO

CH2

CH2

COO–

COO–

C O CH2

CH2

COO–

COO–

CH2

COO–

COO–

C O

COO–

COO–

C OHH

CH2

COO–

COO–

CH

HC

C

CH2

CH2

COO–

O SCoA

O

SCoA

Oxaloacetate

Acetyl CoA

Succinyl CoA

CH3C

α-Ketoglutarate

Malate

Succinate

Isocitrate

Citrate

Fumarate

NAD+

GDPGTP NADH and H +

CO2

CO2

FADH2

FAD

H2O

H2O

H2O

Excreted by lungs

CoA–SH

CoA–SH

CoA–SH + Pi

FIG 3.16 Chemical structures of the compounds of the citric acid cycle (Krebs cycle). In a series of enzymatic reactions, carbon atoms are cleaved to form CO2 and high-energy hydride ions, which are carried by FAD and NAD.

CHAPTER 3 Cell Structure and Function 39

H+ H+ H+

H+ H+ H+ H2O

Matrix space O2 +

Inner mitochondrial membrane

NADH dehydrogenase complex (monomer) b-c1 complex (dimer)

Ubiquinone (cytochrome Q)

Q

C

Cytochrome c

Cytochrome oxidase complex (dimer)

4 Electrons

4H+

2e–

NAD+NADH

FIG 3.17 Representation of the electron transport chain located in the inner mitochondrial membrane. High-energy electrons are passed along the chain until they combine with oxygen to form water. The energy released at each electron transfer is used to pump H+ across the membrane.

H+H+

ADP Pi

ATP

+

FIG 3.18 Inner mitochondrial ATP synthetase captures the potential energy of the H+ gradient in a manner similar to a turbine. The proton gradient drives the synthesis of ATP from adenosine diphosphate (ADP) and inorganic phosphate (Pi). A 360-degree rotation of the rotor requires 12 H+ ions and produces 3 ATP molecules.

KEY POINTS • Energy-requiring reactions within cells are driven by coupling to adenosine

triphosphate (ATP) hydrolysis. • ATP is not stored and must be continuously synthesized by each cell to

meet the cell’s energy needs. • Glycolysis is an anaerobic process that produces two ATP molecules, two

NADH molecules, and two pyruvate molecules per glucose molecule. Pyruvate enters the mitochondria and is converted to acetyl CoA with release of a CO2 molecule. Pyruvate can also be converted to lactate when oxygen supply is insufficient for oxidative processes.

• The citric acid cycle in the mitochondrial matrix oxidizes the acetyl groups supplied by acetyl CoA to form large quantities of H− (hydride ions), which are carried to the respiratory chain by NADH and FADH2.

• The respiratory chain enzymes capture the energy from electron transfer and use it to produce an H+ (proton) gradient. Molecular oxygen is required at this stage (aerobic) to accept the electrons from the last enzyme in the transport chain.

• ATP is produced by ATP synthase, a protein in the mitochondrial membrane. ATP synthase produces ATP by capturing the energy of the proton gradient and using it to form a bond between ADP and inorganic phosphate (Pi). In total, about 30 ATP molecules are produced per glucose molecule.

to flow back into the mitochondria down their electrochemical gradient. The energy of the proton flow is used to drive ATP synthesis (Fig. 3.18). Under normal cellular conditions about 30 ATP molecules are formed from the complete oxidation of glucose into CO2 and H2O. Two of these are from glycolysis, two from the citric acid cycle (in the form of GTP), and the remainder from oxidative phosphorylation. The ATP formed within the mitochondria is transported to the cytosol by protein transporters in the mitochondrial membrane. The ATP is then available to drive a variety of energy-requiring reactions within the cell.

transport proteins discussed earlier. Rather, macromolecules are ingested and secreted by the sequential formation and fusion of membrane-bound vesicles. Endocytosis refers to cellular ingestion of extracellular molecules. The process of cellular secretion is called exocytosis. There are two types of endocytosis, which are differentiated by the size of the particles ingested. Pinocytosis, or “cellular drinking,” is the method of ingesting fluids and small particles and is common to most cell types. Phagocytosis, or “cellular eating,” involves the ingestion of large particles, such as microorganisms, and is practiced mainly by specialized phagocytic WBCs. Endocytosis begins at the cell surface by the formation of an indentation, or “pit,” in the plasma membrane, which is coated with special proteins, including clathrin (coated pit). The indentation invaginates and then pinches off a portion of the membrane to become a vesicle (Fig. 3.19). Each vesicle thus formed is internalized, sheds its coat, and fuses with an endosome. The contents of these endocytic vesicles usually accumulate in lysosomes, where they are degraded.

FUNCTIONS OF THE PLASMA MEMBRANE Membrane Transport of Macromolecules Endocytosis and Exocytosis The transport of large molecules, such as proteins and polysaccharides, across the plasma membrane cannot be accomplished by the membrane

40 UNIT II Cellular Function

genes for making LDL receptor proteins (familial hyperlipidemia) and are incapable of taking up adequate amounts of LDL. Accumulation of LDL in the blood predisposes these individuals to development of atherosclerosis and heart disease (see Chapter 18).

Exocytosis is essentially the reverse of endocytosis. Substances to be secreted from the cell are packaged in membrane-bound vesicles and travel to the inner surface of the plasma membrane. There the vesicle membrane fuses with the plasma membrane, and the contents of the vesicle arrive at the cell surface. Some secreted molecules may remain embedded in the cell membrane, others may be incorporated into the extracellular matrix, and still others may enter the extracellular fluids and travel to distant sites. Many substances synthesized by the cell, including new membrane components, are constantly being packaged and secreted. This continuously operative and unregulated pathway is termed constitutive. In some specialized cells, selected proteins or small molecules are packaged in secretory vesicles, which remain in the cell until the cell is triggered to release them. These special secretory vesicles are typically regulated by stimulation of cell surface receptors. For example, the mast cell, a special type of WBC, releases large amounts of histamine when its cell surface receptors are activated (see Chapter 9).

Membrane Transport of Small Molecules All cells must internalize essential nutrients, excrete wastes, and regulate intracellular ion concentrations. However, the lipid bilayer is extremely

Endocytosis of certain macromolecules is regulated by specific receptors on the cell surface. These receptors bind the molecules (ligands) to be ingested and then cluster together in coated pits. The receptor– ligand complexes are internalized by the invagination process described previously. The vesicles generally fuse with endosomes where the ligand is removed from the receptor for processing by the cell. The receptor may be degraded in the lysosome or may be recycled to the cell surface to be used again. Receptor-mediated endocytosis allows the cell to be selective about the molecules ingested and to regulate the amount taken into the cell. The cell can produce greater numbers of cell surface receptors to ingest more ligand.

An example of receptor-mediated endocytosis is the cellular uptake of cholesterol. The process of cholesterol uptake by cells is shown in Fig. 3.20. Most cholesterol in the blood is transported by protein carriers called low-density lipoproteins (LDLs). The cell can regulate the number of LDL receptors on its cell surface to increase or decrease the uptake of cholesterol. Once the LDL binds to its receptor, this complex is rapidly internalized in a coated pit. The coated vesicle thus formed sheds its coat and fuses with an endosome. In the endosome, the LDL receptor is retrieved and recycled to the cell surface to be reused. The LDL is transported to lysosomes and degraded to release free cholesterol, which the cell uses for synthesis of biomolecules such as steroid hormones.

Dangerously high blood cholesterol levels occur in some individuals who lack functional LDL receptors. These individuals inherit defective

B

A

FIG 3.19 A, Representation of the steps of endocytosis. An invagination of the membrane occurs and pinches off to form a vesicle. Exocytosis progresses in essentially the reverse sequence. B, Electron micrograph showing the steps of endocytosis. (B, From Perry M, Gilbert A: Yolk transport in the ovarian follicle of the hen [Gallus domesticus]: lipoprotein-like particles at the periphery of the oocyte in the rapid growth phase, J Cell Sci 39:257–272, 1979.)

CHAPTER 3 Cell Structure and Function 41

LDL

Coated pit with LDL receptors

Endosome

Endocytosis

Vesicle

Lysosome

Fusion of vesicle and lysosome

Free cholesterol for cell use

Receptors recycled to cell surface

FIG 3.20 Steps in the process of receptor-mediated endocytosis of cholesterol. Cholesterol is carried in the blood by LDL. The uptake of LDL with its associated cholesterol, is mediated by a specific LDL-receptor protein on the cell surface. Once internalized, the cholesterol is removed from the LDL-receptor complex and used by the cell. The LDL receptors are sent back to the cell surface to bind more LDL.

impermeable to most polar and charged molecules. Transport of small water-soluble molecules is achieved by specialized transmembrane proteins called transporter proteins. Most membrane transporters are highly specific—a different transporter protein is required for each type of molecule to be transported. Only lipid-soluble molecules can permeate the lipid bilayer directly by simple diffusion.

Membrane transport proteins are of three basic kinds: ATP-driven pumps, carriers, and channel proteins. Channel proteins are the simplest of the three, forming a water-filled pore through the lipid bilayer. These pores are able to open and close to allow ions to pass through the membrane. The particular structure of the protein channel ensures that only ions of a certain size and charge can move through the membrane. Pumps and carrier proteins, however, bind to the solute to be transported and move it through the membrane by undergoing a structural, or conformational, change. Pumps and carriers have a transport maximum that is much lower than that of channels because they must bind to the molecules to be transported and then move them through the membrane. Pumps and carriers, which transport ions and nonelectrolyte molecules (e.g., glucose and amino acids), are also highly specific for the substances they transport.

Lipid-soluble particles can cross the lipid bilayer directly by simple diffusion through the hydrophobic lipid portion of the membrane. Polar or charged molecules must cross the membrane via protein channels or carriers. Transport through membrane proteins may be a passive or an active process. Passive transport through membrane proteins is called facilitated diffusion. Diffusion of ions occurs passively because of an electrochemical gradient. The electrochemical gradient exists because of differences in intracellular and extracellular charge and/or concentration of chemicals and is governed by laws of physics. Channel proteins only allow particles to move down their electrochemical or concentration

gradients. Some carriers are passive, but others use the movement of one ion flowing down its concentration gradient (usually Na+ moving into the cell) to move another substance uphill against its gradient. This process is called secondary active transport because ATP is not used directly; however, ATP is necessary to run the pumps that maintain the sodium gradient. The lipid bilayer is fairly impermeable to water because of its polar structure. Water moves across the plasma membrane through channels called aquaporins. Nearly all cells have aquaporins present in their cell membranes at all times, with the exception of a few specialized cells in the kidney tubules. Net movement of water across a membrane (osmosis) occurs in response to differences in osmotic pressure on either side of the membrane and is a passive process.

Active Transport Pumps Active transport is the process whereby protein transport pumps move solutes across the membrane against an electrochemical or concentration gradient. Primary active transport requires metabolic energy, which is supplied by ATP hydrolysis. There are three families of ATP-driven pumps: the F-type ATPases that move H+; the P-type adenosine tri- phosphatase (ATPase) that pump ions across membranes; and the ATP-binding cassette (ABC) transporters that transport a wide range of solutes. The ATP synthase located on the inner mitochondrial membrane is an example of an F-type pump; however, in that location it runs backward, allowing H+ to run down its electrochemical gradient, and uses the energy to form a bond between ADP and Pi (see Fig. 3.18). As a general principle, pumps, carriers, and channels can transport in either direction depending on the concentration of substrates on either side of the membrane.

Sodium–potassium ion pump. The sodium–potassium (Na+–K+) pump is a P-type ATPase present in the plasma membranes of virtually

42 UNIT II Cellular Function

ABC transporters. Another important class of ATP-driven transport- ers is the ABC transporter family. These transporters all have a common ATP-binding domain, called the ATP binding cassette (ABC), which hydrolyzes ATP to provide energy for the transport process (Fig. 3.23). This family of membrane transporters is the largest of the transporter families. A clinically important member of this family is a chloride channel in the plasma membrane of epithelial cells. A defect in this transporter is responsible for cystic fibrosis, a common genetic disorder that affects the lungs and pancreas (see Chapter 22). Bacteria use ABC transporters to pump antibiotics out of the cell, resulting in drug resistance (see Chapter 8).

Membrane Transport Carriers Na+-driven carriers. In animal cells, the Na+ gradient created by

the Na+–K+ pump is used to power a variety of transporters by secondary active transport. An important Ca2+ transporter located in the plasma membrane of cardiac muscle cells uses the electrochemical gradient of Na+ to power the transport of Ca2+ out of the cell (see Fig. 3.22, right). The dependence of this calcium transporter on the sodium gradient helps explain the inotropic effects of the commonly prescribed drug digitalis. Digitalis is a cardiac glycoside that inhibits the Na+–K+ pump and allows the accumulation of intracellular Na+. The Na+ concentration gradient across the membrane is thus decreased, leading to less efficient calcium removal by the Na+-dependent Ca2+ pump. A more forceful cardiac muscle contraction results from the increased intracellular Ca2+ concentration. Another example of a transporter that uses secondary active transport is the Na+–H+ exchange carrier, which uses the Na+ gradient to pump out excess hydrogen ions to help maintain intracellular pH balance. The Na+ gradient also can be used to bring substances into the cell. For example, glucose and amino acid transport into epithelial cells is coupled to Na+ entry. As Na+ moves through the transporter down its electrochemical gradient, the sugar or amino acid is “dragged” along. Entry of the nutrient will not occur unless Na+ also enters the cell. The epithelial cells that line the gut and kidney tubules have large numbers of these nutrient transporters present in the luminal (apical) surfaces of their cell membranes. In this way, large amounts of glucose and amino acids can be effectively absorbed. The reuptake of numerous types of neurotransmitters from synapses also occurs via Na+-driven

all animal cells. It serves to maintain low sodium and high potassium concentrations in the cell. The Na+–K+ transporter must pump ions against a steep electrochemical gradient. Almost one-third of the energy of a typical cell is consumed by the Na+–K+ pump. ATP hydrolysis provides the energy to drive the Na+–K+ transporter. The Na+–K+ pump behaves as an enzyme in its ability to split ATP to form ADP and Pi, leading to the protein being termed Na+–K+ ATPase.

Transport of sodium and potassium ions through the Na+–K+ carrier protein is coupled; that is, the transfer of one ion must be accompanied by the simultaneous transport of the other ion. The transporter moves three sodium ions out of the cell for every two potassium ions moved into the cell (Fig. 3.21). The Na+–K+ pump is important in maintaining cell volume. It controls the solute concentration inside the cell, which in turn affects the osmotic forces across the membrane. If Na+ is allowed to accumulate within the cell, the cell will swell and could burst. The role of the Na+–K+ pump can be demonstrated by treating cells with digitalis, a drug that inhibits Na+–K+ ATPase. Cells thus treated will indeed swell and often rupture. The Na+–K+ pump is responsible for maintaining a steep concentration gradient for Na+ across the plasma membrane. This gradient can be harnessed to transport small molecules across the membrane in a process called secondary active transport. Carriers that use ATP directly are engaged in primary active transport.

Membrane calcium transporters. Numerous important cellular processes, such as cell contraction and growth initiation, are dependent on the intracellular calcium ion concentration. Intracellular Ca2+ is normally very low and tightly regulated. Two important calcium pumps, present in the plasma membrane and in the ER (sarcoplasmic reticulum of muscle cells), function to remove Ca2+ from the cell cytoplasm. Similar to the Na+–K+ transporter, these transporters use ATP as the energy source (Fig. 3.22, left).

If calcium ion levels in the cytoplasm become dangerously elevated, calcium pumps in the mitochondrial membrane are activated. Calcium ions are actively pumped into the mitochondria using the energy of the proton (H+) gradient. This is the same proton gradient that the mitochondria use to synthesize ATP, and ATP production declines when the mitochondria are required to sequester Ca2+. A high intracellular Ca2+ level is even more dangerous to the cell than a reduction in ATP production.

Extracellular fluid

Cytoplasm

Na+ binding site

K+ binding site

K+

K+

Na+ Na+ Na+

ATP

ADP + Pi

FIG 3.21 Schematic drawing of the sodium–potassium transport protein, which uses ATP to pump Na+ out of the cell and K+ into the cell against steep electrochemical gradients. This transporter is responsible for maintaining a low intracellular concentration of Na+ and a large Na+ gradient across the membrane. The energy of this Na+ gradient can be harvested by other transporters to actively transport substances.

Extracellular fluid

Cytoplasm

Ca2+ Ca 2+

Na+ gradient

Sodium gradient–dependent

Ca2+ pump

ATP-dependent

Ca2+ pump

Na+ ATP ADP + Pi

FIG 3.22 Two transporters of calcium ions are present in some cell membranes. One uses ATP as the energy source to pump calcium against a gradient (primary active transport). The other captures the potential energy of the sodium gradient to pump calcium out of the cell (secondary active transport).

CHAPTER 3 Cell Structure and Function 43

carrier proteins. The movement of Na+ through carriers located in the presynaptic neuron drags the neurotransmitter from the synapse back into the nerve terminal, where it can be repackaged for reuse or metabolized by cellular enzymes.

Passive transport carriers. Some carriers are not linked to the Na+ gradient and move substances across the membrane passively. The glucose transporters in many cell types belong to this class of transporters. In β cells of the pancreas, for example, the glucose transporters (Glut-1)

Extracellular fluid

Cytoplasm ATP

ADP Pi

ATP-binding cassette

FIG 3.23 The ABC transporters are the largest known family of membrane transport proteins. They are characterized by an ATP-binding domain that causes a substrate pocket to be exposed first on one side of the membrane and then on the other as ATP is bound and hydrolyzed to ADP and Pi.

are always present in the plasma membrane and let glucose into the cell according to its concentration in the extracellular fluid. In this way the pancreas detects blood glucose levels and releases an appropriate amount of insulin. In insulin-sensitive cells, such as muscle, liver, and adipose cells, the glucose carriers are sequestered inside the cell until insulin binds to its receptor at the cell surface. Receptor activation causes the glucose carriers (Glut-4) to move to the cell surface, where they allow passive influx of glucose (Fig. 3.24).

Glucose

Signal from insulin

receptor

Translocation to cell

surface

Sequestered Glut–4

transporters

Insulin

Insulin receptor

FIG 3.24 In response to insulin binding to its receptor on the cell surface, carrier proteins that transport glucose (Glut-4) are moved to the cell surface where they passively transport glucose into the cell (facilitated diffusion).

44 UNIT II Cellular Function

Membrane Channel Proteins In contrast to carrier proteins, which bind molecules and move them across the membrane by a conformational change, channel proteins form water-filled pores in the membrane. Nearly all channel proteins are involved in transport of ions and may be referred to as ion channels. Ions can flow through the appropriate channel at very high rates (100 million ions/sec); this is much faster than carrier-mediated transport. However, channels are not linked to an energy source, so ions must flow passively down an electrochemical gradient. The channel proteins in the plasma membranes of animal cells are highly selective, permitting only a particular ion or class of ions to pass. Humans have about 400 genes that encode channel proteins. Ion channels are particularly important in allowing the cell to respond rapidly to a variety of external stimuli. Most channels are not continuously open, but they open and close according to membrane signals. Ion channels may be stimulated to open or close in three principal ways: (1) voltage-gated channels respond to a change in membrane potential; (2) mechanically gated channels respond to mechanical deformation; and (3) ligand-gated channels respond to the binding of a signaling molecule (a hormone or neurotransmitter) to a receptor on the cell surface (Fig. 3.25). In addition, some channels open without apparent stimulation and are referred to as leak channels. Ion channels are responsible for the

FIG 3.25 Gating of ion channels. A, Voltage-gated channel. B, Ligand-gated channel. C, Mechanically gated channel.

development of membrane potentials and are of vital importance in nerve and muscle function, as discussed in the next section.

KEY POINTS • Large, lipid-insoluble molecules are transported across the plasma membrane

by endocytosis and exocytosis. • Small, lipid-insoluble molecules are transported across the plasma membrane

by three kinds of membrane proteins: adenosine triphosphate (ATP)-driven pumps, carriers, and channels.

• Pumps use the energy of ATP to move solutes against a gradient. Examples of ATP-driven active transport include proton pumps, Na+–K+ pumps, Ca2+ pumps, and ATP-binding cassette (ABC) transporters.

• Carriers may be passive or use the Na+ gradient for secondary active transport. Neurotransmitter reuptake carriers and those that transport glucose and amino acids across the gut and renal tubules are examples of Na+-driven carriers. Passive carriers include those that allow glucose entry into insulin- sensitive cells.

• Channels are always passive and allow ions to move down their electrochemi- cal gradients when open. Channels open and close in response to specific signals, such as voltage changes, ligand binding, and mechanical pressure.

CHAPTER 3 Cell Structure and Function 45

potential of about −85 mV. If the extracellular K+ level is increased, more K+ ions will stay in the cell because of the reduced concentration gradient. These extra positive intracellular ions will neutralize more of the negative cellular anions, and the cell will hypopolarize, or become less negative. Conversely, if extracellular K+ levels fall, more K+ will exit the cell due to a greater concentration gradient. Fewer intracellular anions will be neutralized, and the cell interior will become more negative, or hyperpolarized (Fig. 3.27). Changes in RMP can have profound effects on the ease of action potential generation in cardiac and nerve cells.

The RMP is described by the potassium equilibrium potential because the cell is relatively impermeable to other ions at rest. Under certain conditions, the membrane may become highly permeable to an ion other than potassium. The membrane potential will reflect the equi- librium potential of the most permeant ions.

Long-term maintenance of ion gradients across the cell membrane is accomplished primarily by the Na+–K+ pump. The Na+–K+ pump also contributes to the negative RMP in that it extrudes three Na+ for every two K+ brought into the cell. However, this pump can be inhibited for minutes to hours in some tissues with little immediate effect on the resting membrane potential.

Action Potential Nearly all animal cells have negative RMPs, which may vary from −20 to −200 mV, depending on the cell type and organism. The cell mem- branes of some specialized cell types, mainly nerve and muscle, are capable of rapid changes in their membrane potentials. These cells are electrically “excitable” and can generate and propagate action potentials. In classic experiments, action potentials were determined to be rapid, self-propagating electrical excitations of the membrane that are mediated by ion channels that open and close in response to changes in voltage across the membrane (voltage-gated ion channels). An action potential is triggered by membrane depolarization.

In nerve and muscle cells, the usual trigger for depolarization is binding of an excitatory neurotransmitter to cell surface receptors. Transmitter binding causes channels in the membrane to open, allowing ions (primarily Na+) to enter the cell. This influx of positive ions causes a shift in the membrane potential to a less negative value, resulting in depolarization. Threshold is reached when a patch of the membrane becomes sufficiently depolarized (approximately −65 mV in animal neurons) to activate voltage- gated sodium channels in the membrane. At threshold, these channels open rapidly and transiently to allow the influx of Na+ ions. A self-propagating process follows whereby Na+ influx in one patch of membrane causes membrane depolarization of the next patch and opens more voltage-gated Na+ channels, allowing more Na+ to enter the cell. This process is repeated many times while the action potential proceeds along the length of the cell (Fig. 3.28). In this way, action potentials can transmit information rapidly over relatively long distances.

A typical neuronal action potential is shown in Fig. 3.29. The various changes in membrane potential during the time course of the action potential are attributable to the flow of ions through membrane ion channels. The steep upstroke of the action potential corresponds to Na+ influx through “fast” sodium channels, as described previously. Fast channels are so termed because they open and close rapidly, with the entire process lasting less than 1 msec. This phase of rapid depolariza- tion is terminated when the fast Na+ channels suddenly close and the repolarization phase begins. Fast Na+ channels are interesting in that they can assume at least three conformations (three-dimensional forms). In addition to the open and closed conformations, the fast Na+ channel has a refractory form during which the channel will not reopen in response to another depolarizing stimulus (Fig. 3.30). This refractory period limits the rate at which action potentials can be generated.

Two major factors contribute to cellular repolarization: sodium conductance (inflow) is stopped by closing Na+ channels, as described

Cellular Membrane Potentials Animal cells typically have a difference in the electrical charge across the plasma membrane. There is a slight excess of negative ions along the inner aspect of the membrane and extra positive ions along the outer membrane. This separation of charges creates a membrane potential that can be measured as a voltage. Positive and negative ions separated by the plasma membrane have a strong attraction to one another that can be used by the cell to perform work, such as the transmission of nerve impulses. A relatively large membrane potential is created by the separation of a very small number of ions along the membrane (Fig. 3.26).

Resting Membrane Potential When there is no net ion movement across the plasma membrane, the electrical charge present inside the cell is called the resting membrane potential (RMP). The major determinant of the RMP is the difference in potassium ion concentration across the membrane. The concentration of potassium inside the cell is much greater (about 30 times greater) than the extracellular potassium concentration. At rest, the membrane is permeable to K+, but not to other positively charged cations, including Na+ and Ca2+. Potassium ions remain inside the cell because of the attraction of fixed intracellular anions (negatively charged organic molecules such as proteins and phosphates that cannot diffuse out of the cell). Because the cell membrane is impermeable to Na+ and Ca2+, only K+ is available to balance these negative intracellular ions. Thus two opposing forces are acting on the potassium ion. The negative cell interior attracts K+ into the cell, whereas the huge K+ concentration gradient favors movement of K+ out of the cell. When the cell is at rest and not transmitting impulses, these forces are balanced, and although the membrane is permeable to K+ there is no net movement. The voltage required to exactly balance a given potassium concentration gradient can be calculated from the ratio of extracellular K+ concentration using the Nernst equation:

mV 61log K extracellular K intracellular= ( + + . The measured membrane potential is quite close to that predicted

mathematically and varies directly with changes in extracellular K+ ion concentration. For example, a typical nerve cell has a normal resting

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ – + – + – + – + – + – + – + – + – + – + – + – + – + – + – + – + –

Extracellular fluid

Plasma membrane

Cytoplasm

FIG 3.26 A relatively large membrane potential results from the separation of a very small number of ions across the plasma membrane.

46 UNIT II Cellular Function

+ + + + + + – – – – – –

+ + – –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+ –

+40

+20

0

–20

–40

–60

–80

–100

M e m

b ra

n e p

o te

n tia

l ( m

V )

Normal serum K+ High serum K+ Low serum K+

Threshold

–90 mV –70 mV –100 mV

FIG 3.27 Effects of changes in extracellular K+ level on the resting membrane potential. A high level of serum K+ results in a hypopolarization of the membrane. A low serum K+ level results in membrane hyper- polarization. With high serum K+ levels, the resting membrane potential is closer to threshold, making it easier to achieve an action potential. A low serum K+ level moves the resting membrane potential away from threshold, making it more difficult to achieve an action potential.

+ + + +–––

+ + +

+ + + + + +

– – –– – –

– – –

––– –––

+ +

+ + +

Na+

Na+

Voltage-gated sodium channels

Open channel Closed channel

Na+ Na+

Na+Na+Na+

AP

AP

AP

Na+Na+

K+K+

A

B FIG 3.28 The action potential (AP) in excitable cells is propagated along the membrane by the sequential opening of voltage-gated sodium channels in adjacent sections of membrane. A, An action potential is initiated by the opening of sodium channels in a section of membrane. B, The action potential is regenerated in adjacent sections of membrane as more sodium channels open. The initial segment repolarizes as sodium channels close and potassium ions move out of the cell.

previously, and K+ conductance (outflow) through K+ channels increases. Although cells are always permeable to K+, during repolarization additional voltage-gated K+ channels open allowing a higher rate of K+ efflux. These K+ channels respond to depolarization of the membrane in the same manner as fast Na+ channels, but they take much longer to open and close. When K+ channels open, K+ flows out of the cell because of the concentration gradient and the loss of intracellular negativity that accompanies Na+ influx. The outward flow of positive intracellular potassium ions helps to quickly return the membrane potential to its negative RMP value.

Action potentials in cardiac muscle cells are more complex than the neuronal ones just described. Recall that contraction depends on the presence of free intracellular calcium ions. Because Ca2+ carries a charge, its entry into the cell cytoplasm is reflected in the membrane potential. In skeletal muscle, most of the free cytosolic calcium ions come from intracellular stores (sarcoplasmic reticulum) that are released when the cell is depolarized. In cardiac muscle cells, Ca2+ entry through voltage- gated channels in the plasma membrane is also important. Calcium conductance into the cell tends to prolong the action potential, resulting in a plateau phase (Fig. 3.31). This is of functional importance in cardiac tissue because it allows time for muscular contraction before another impulse is conducted and prevents the potentially disastrous condition of cardiac muscle tetany. (For a more thorough discussion of cardiac electrophysiology, see Chapter 17.)

KEY POINTS • The negative value of the resting membrane potential (RMP) is determined

by the ratio of intracellular to extracellular K+ ion concentration. Changes in serum K+ concentration can have profound effects on the RMP.

• Cells with voltage-gated ion channels are excitable and can produce and conduct action potentials. An action potential results from the opening of “fast” Na+ channels, which allows Na+ to rush into the cell.

• Repolarization is caused by closure of Na+ channels and efflux of K+ from the cell. In cardiac muscle, repolarization is prolonged due to Ca2+ influx through “slow” Ca2+ channels.

CHAPTER 3 Cell Structure and Function 47

+50

0

–50

–100

10

1

0.1

0.01

M e m

b ra

n e p

o te

n tia

l ( m

V )

C o n d u ct

a n ce

( m

m h o /c

m 2 )

K+ Na+

Milliseconds

0.005

0 0.5 1.0 1.5

Action potential

Overshoot

FIG 3.29 A typical neuronal action potential showing changes in membrane potential and the associated ion conductances. Note: mmho is a measure of conductance (amperes per volt), also called millisiemens (mS). The steep upstroke of the action potential is attributed to the sudden influx of Na+ through voltage-gated “fast” sodium ion channels. Voltage-gated K+ channels open more slowly and stay open longer to allow K+ efflux from the cell, which aids in repolarization.

FIG 3.30 Three possible states of the voltage-gated sodium channel. In the open state, Na+ is allowed to pass. In the refractory state, the channel is blocked by the inactivation gate and will not open in response to a depolarizing stimulus. In the closed state, the channel will open in response to a membrane depolarization.

48 UNIT II Cellular Function

FIG 3.31 A typical cardiac muscle cell action potential showing the ion fluxes associated with each phase. Note that the repolarization phase is prolonged in comparison to the nerve action potential in Fig. 3.28. This occurs because Ca2+ influx offsets the repolarizing effect of K+ efflux and a plateau in the membrane potential is seen. When the Ca2+ channels close, the membrane quickly repolarizes.

INTERCELLULAR COMMUNICATION AND GROWTH Cell Signaling Strategies Cells in multicellular organisms need to communicate with one another and respond to changes in the cellular environment. Coordination of growth, cell division, and the functions of various tissues and organ systems are accomplished by three principal means of communication: (1) through gap junctions that directly connect the cytoplasm of adjoining cells; (2) by direct cell-to-cell contact of plasma membranes or the extracellular molecules associated with the cell (extracellular matrix); and (3) by secretion of chemical mediators (ligands) that influence cells some distance away (Fig. 3.32).

Gap junctions are found in many tissues. They are connecting chan- nels between adjacent cells that allow the passage of small molecules from one cell to the next. These junctions are formed by special transmembrane proteins called connexins that associate to form pores of about 1.5 nm in width. Small molecules, such as inorganic ions, glucose, amino acids, and vitamins, may pass through the pores, whereas macromolecules (e.g., proteins, polysaccharides, and nucleic acids) are too large to pass through pores. Gap junctions are particularly important in tissues in which synchronized functions are required, such as cardiac muscle contraction, vascular tone, and intestinal peristaltic movements. Gap junctions appear to be important in embryogenesis as well. Cellular differentiation may be mediated in part through chemical signaling through gap junctions. (See Chapter 5 for a discussion of the development and differentiation of tissue types.)

Direct contact of cell membrane receptors with signaling molecules present on the surface of other cells or extracellular matrix is an important means of local communication among cells in tissues. Contact-dependent signaling is particularly important for the development of the immune

Signaling cell

Signaling molecule

REMOTE SIGNALING BY SECRETED MOLECULES

DIRECT SIGNALING BY PLASMA MEMBRANE–BOUND MOLECULES OR EXTRACELLULAR MATRIX

DIRECT SIGNALING VIA GAP JUNCTIONS

Target cell

Receptor

Signaling cell

Signaling molecule

Target cell

Receptor

Matrix

FIG 3.32 Methods used for intercellular communication.

CHAPTER 3 Cell Structure and Function 49

Abnormal autocrine stimulation is thought to be a mechanism in some forms of cancer (see Chapter 7).

Target cells respond to ligand signaling through specific protein receptors. Cells can respond to a particular ligand only if they possess the appropriate receptor. For example, all cells of the body are exposed to thyroid-stimulating hormone (TSH) as it circulates in the blood, but only thyroid cells respond because they alone possess TSH receptors. However, cells that possess the same receptor may respond very differently to a particular ligand. For example, binding of acetylcholine to its receptor on a glandular cell may induce secretion, whereas binding to the same receptor on a cardiac muscle cell causes a decrease in contractile force. The cellular response to signaling molecules is regulated both by the array of receptors the cell carries and by the internal machinery to which the receptors are linked.

Cell Surface Receptor–Mediated Responses Most hormones, local chemical mediators, and neurotransmitters are water-soluble molecules that are unable to pass through the lipid bilayer of the cell. These ligands exert their effects through binding with a receptor on the surface of the target cell, which then changes or transduces the external signal into an intracellular message. There are three major classes of cell surface receptor proteins: ion channel–linked, enzyme- linked, and G-protein–coupled (Fig. 3.35).

Ion channel–linked receptors bind neurotransmitters, causing specific ion channels in the membrane to open or close. This type of signaling is prevalent in the nervous system, where rapid synaptic signaling between neurons is required. Enzyme-linked receptors catalyze enzyme reactions when they are activated by appropriate ligands. Nearly all enzyme-linked receptors function as protein kinases; that is, they mediate the transfer of phosphate groups from ATP (or GTP) to proteins (phosphorylate), and thus affect the activity of those target proteins. The insulin receptor and most growth factor receptors are protein kinase receptors that phosphorylate and activate intracellular enzyme cascades. Enzyme- linked kinase receptors activate common kinase cascades, including the

response. Such cell-to-cell contact during fetal development is thought to allow the cells of the immune system to discriminate between foreign and self tissues and to develop self-tolerance. If cell-to-cell contact does not occur during fetal life, the immune cells may later attack the body’s own cells, leading to the development of autoimmune diseases. (See Chapter 10 for a discussion of autoimmunity.) There are four major families of cell adhesion molecules (CAMs): immunoglobulin–cell adhesion molecules (Ig-CAMs), cadherins, integrins, and selectins. These cell adhesion proteins make contacts between cells and with the extracellular matrix and provide signals that maintain cell survival and differentiated cell types (Fig. 3.33).

The best understood form of cell communication is signaling through secreted molecules, or ligands. Three strategies of intercellular chemical signaling have been described, relating to the distances over which they operate (Fig. 3.34). Synaptic signaling is confined to the cells of the nervous system and occurs at specialized junctions between the nerve cell and its target cell. The neuron secretes a chemical neurotransmitter into the space between the nerve and target cell; the neurotransmitter then diffuses across this synaptic cleft and binds receptors on the postsynaptic cell. Synaptic signaling occurs over very small distances (50 nm) and involves only one or a few postsynaptic target cells. In paracrine signaling, chemicals are secreted into a localized area and are rapidly destroyed, so that only cells in the immediate area are affected. Growth factors (GFs), for example, act locally to promote wound healing without affecting the growth of the entire organism. Endocrine signaling is accomplished by specialized endocrine cells that secrete hormones that travel via the bloodstream to target cells widely distributed throughout the body. Endocrine signaling is slow in comparison to nervous signaling because it relies on diffusion and blood flow to target tissues.

A fourth type of signaling, autocrine signaling, occurs when cells are able to respond to signaling molecules that they secrete. Autocrine communication provides a feedback signal to the secreting cell and is commonly linked to pathways that regulate ligand secretion rates.

Extracellular Fluid

Cytoplasm

Fibronectin

Collagen fiber

Plasma membrane

Cytoskeleton

Integrin

Proteoglycan

Matrix

FIG 3.33 Cell adhesion proteins interact with the extracellular matrix (integrins) and with neighboring cells to maintain cell survival and differentiation. (Redrawn from Patton KT, Thibodeau GA: Anatomy & physiology, ed 9, St. Louis, 2016, Mosby, p. 141.)

50 UNIT II Cellular Function

A

B

C

D

Extracellular space

Bloodstream

Synapse

Signaling cell Synaptic

Paracrine

Endocrine (hormonal)

Autocrine

Target cell

Ligands

FIG 3.34 Signaling by secreted ligands can occur over variable distances. A, Synaptic signaling over a very small distance between neuron and target cell. B, Paracrine signaling through the extracellular fluid between cells in a tissue. C, Long-range signaling from endocrine cells through the bloodstream to distant targets. D, Localized autocrine signaling in which the secreting cell is also the target cell.

Ligand

Ion

A Ion channel–linked receptor

B Enzyme-linked receptor

C G-protein–linked receptor

P

Ligand

Protein kinases

Ligand

Trimeric G-protein

Enzyme

Second messenger

γα β

GTPATP

FIG 3.35 There are three major types of cell surface receptor proteins. A, Ion channel–linked receptors are also called ligand-gated channels. When the ligand binds, they open to allow specific ions through the membrane. B, Enzyme-linked receptors become activated kinases when a ligand binds to them. Kinases phosphorylate target proteins and change their activity. C, G-protein–linked (coupled) receptors have seven membrane-spanning segments with a ligand-binding pocket on the outside and a G-protein–activating portion on the inside. G-protein–linked receptors activate G-proteins, which in turn influence enzymes that produce second messengers.

CHAPTER 3 Cell Structure and Function 51

P P P P P P

RAS PI3K JAK

MAP kinases Protein

kinase B (AKt)

Target genes

STAT

GTP

FIG 3.36 Many growth factor receptors activate protein kinase cascades within the cell. Three common pathways are shown. After binding of ligand, the receptor dimerizes and becomes phosphorylated. A cascade of kinase activations is initiated resulting in a change in target gene transcription. GTP, Guanosine triphosphate; JAK, janus kinase; MAP, mitogen-activated kinase; PI3K, phosphoinositide 3-kinase; RAS, rat sarcoma protein; STAT, signal transducer and activator of transcription.

PI3K-protein kinase B pathway, the RAS-MAP kinase pathway, and the JAK-STAT pathway (Fig. 3.36).

A large number of signaling ligands bind to G-protein–coupled receptors (GPCRs). Most hormones and many drugs have their effects through G-protein–linked cascades. G-protein–coupled receptors act indirectly through a membrane-bound trimeric G-protein that binds GTP when activated by the receptor. The activated α subunit of the trimeric G-protein influences the activity of specific target enzymes. The target enzymes of G-proteins produce second messengers that trigger specific intracellular cascades and alter cell function (Fig. 3.37). The α subunit of G-proteins has intrinsic enzyme activity that degrades GTP into GDP and Pi after a time. When GTP is bound, the G-protein is in the right conformation to activate its downstream targets, but when GTP is hydrolyzed to GDP and Pi, the G-protein resumes its inactive conformation and the activity of the signaling cascade is terminated.

There are three principal G-protein–coupled signaling systems that, when activated, alter the intracellular concentration of one or more second messengers (see Fig. 3.37). Numerous receptors activate trimeric G-proteins whose α subunit stimulates adenylyl cyclase to produce the second messenger cyclic adenosine monophosphate (cAMP). These G-proteins are called Gs. An increase in cAMP concentration is linked to different signaling cascades in different cell types. For example, cAMP causes glycogen breakdown in liver cells, increased force of contraction in cardiac cells, and increased secretion by glandular cells. Various cell types respond differently to the same second messenger because of differences in enzymes and other proteins in the cell.

Another important G-protein–coupled cascade is mediated by G-proteins called Gq whose α subunit stimulates the enzyme phospho- lipase C. Phospholipase C cleaves a membrane phospholipid (PI[4,5] P2) to form two second messengers: inositol 1,4,5-trisphosphate (IP3)

and diacylglycerol (DAG) (see Fig. 3.37). The IP3 travels to the ER, where it stimulates the release of Ca2+ into the cytoplasm. The Ca2+ then triggers a change in cell function. DAG remains bound to the inner surface of the plasma membrane and can trigger several different intracellular cascades. Two important targets are the protein kinase C pathway and the eicosanoid pathway. Protein kinase C is a key enzyme in the growth response. The eicosanoid pathway results in the production of several arachidonic acid derivatives, including prostaglandins. These products are often secreted by the cell as signaling molecules to other nearby cells. Prostaglandins are important mediators of inflammation and platelet function.

The third trimeric G-protein type is called Gi because it is inhibitory to the production of cAMP. GPCRs such as the acetylcholine receptor in the heart activate Gi, whose α subunit then inhibits adenylyl cyclase (see Fig. 3.37). In this case the γβ subunit of Gi is also activated and opens membrane potassium channels in the heart, which tend to slow the heart rate. Although Gs, Gq, and Gi are the primary trimeric G-protein signaling cascades, others have been described (Table 3.1).

In addition to the four second messengers already mentioned (cAMP, IP3, DAG, and Ca

2+) there is a fifth called cyclic guanosine monophosphate (cGMP), which is produced by the enzyme guanylyl cyclase (Fig. 3.38). The primary activator of guanylyl cyclase is a small lipid-soluble gas molecule called nitric oxide. Nitric oxide is an important signaling molecule with widespread targets. It functions as a neurotransmitter in the brain and is an important smooth muscle relaxant in the vascular system. cGMP is also produced by a special class of enzyme-linked receptors (see Fig. 3.38).

To be effective at communicating signals, all the receptor systems must be quickly turned off so that they can be responsive to the next incoming signal. A variety of strategies are used to quench the signaling

52 UNIT II Cellular Function

GTP

γ β αq αq

Gq Pathway

γ β γ βαi

Gi Pathway

GTP Eicosanoids

Phospholipase C

Enzyme activation

Protein kinase C

Adenylyl cyclase

P

P P

P

P P

PIP2

Ca2�

ER

(or)

IP3

Cellular effects

DAG

cAMP

Protein kinase AHydrolysis inactivates

Hydrolysis inactivates

γ β αs αs

Gs Pathway

GTP GTP

On

On

On

Off

GDP/Pi

Off

GDP/Pi

Hydrolysis inactivates

Off

GDP/Pi

GTP

GTP

ATP

Cellular effects

K� channel opening

Adenylyl cyclase

Inhibits AC and ↓cAMP

A

B

C

αi

FIG 3.37 G-protein–coupled signaling. When the ligand binds to the receptor, an intracellular domain is changed into an active configuration that can interact with inactive trimeric G-proteins. The receptor induces the G-protein to release its bound GDP and Pi in exchange for a GTP molecule. When GTP binds to the α subunit of the G-protein, it is activated and diffuses away from the γβ subunits to find its target enzyme (adenylyl cyclase [AC] or phospholipase C). The α GTP stimulates its target enzyme to produce a second messenger, which in turn activates a signaling cascade within the cell. After a time, the α subunit hydrolyzes its GTP to GDP and Pi and becomes inactive. The α subunit is now in the correct conformation to reassociate with the γβ subunits and await another signal from the receptor. A, The Gs pathway increases the production of cyclic adenosine monophosphate (cAMP). B, The Gq pathway increases the production of inositol 1,4,5-tri- sphosphate (IP3) and diacylglycerol (DAG). C, The Gi pathway is inhibitory to the production of cAMP. In some cases the γβ subunit also has functional activity and may regulate ion channels. ER, Endoplasmic reticulum; PKC, protein kinase C.

CHAPTER 3 Cell Structure and Function 53

phosphorylate G-protein receptors are called G-protein–receptor kinases (GRKs). The mechanisms that “turn off” signaling cascades are vitally important to maintaining a responsive communication system.

Intracellular Receptor–Mediated Responses A small number of hormones are lipid soluble and can pass directly through the cell membrane to interact with receptors inside the cell. These receptors are located in the cell cytosol (e.g., cortisol) or may be associated with the cell nucleus. Intracellular receptors are specific for a particular ligand, just as surface receptors are. Binding of the ligand causes the receptor to become activated. Because lipid-soluble ligands enter the cell directly, no second messengers are needed. An activated cytosolic steroid receptor travels to the nucleus, where it binds with specific genes and regulates their activity (Fig. 3.40). Thyroid receptors are also located within the cell. Thyroid hormone enters the cell through carriers in the membrane and travels to the nucleus. The thyroid receptor is already bound to DNA in the absence of thyroid hormone. When thyroid hormone finds its nuclear receptor, the complex dissociates and removes an inhibitory influence on gene transcription. Cellular responses to these gene regulatory receptor complexes are slow in comparison to the cell surface receptor responses and generally last longer.

cascades (Fig. 3.39). For example, phosphodiesterases are enzymes that convert the cyclic nucleotides cAMP and cGMP to their inactive forms, AMP and GMP, respectively, and help to remove these second messengers soon after they are formed. Some drugs, such as caffeine and sildenafil citrate (Viagra), are phosphodiesterase inhibitors that slow the normal breakdown of cyclic nucleotides and prolong their activity. Many of the intracellular signaling cascades rely on kinases that phosphorylate their target proteins and change their activity. The action of kinases is countered by numerous phosphatase enzymes that quickly cleave the phosphates off the target proteins and inhibit their activity.

The cell also can regulate the activity and number of receptors on the cell surface. Generally a cell decreases the number or activity of receptors when it is exposed to excessive concentrations of signaling molecules (see Fig. 3.39). Receptors can be internalized in the cell where they are inactive but are available for later use, or they can be sent to lysosomes for degradation. Destruction of receptors in lysosomes is called down-regulation. (The production of extra receptors is called up-regulation.) Receptors that remain in the membrane also can be inhibited by phosphorylation, which blocks them from interacting with their intracellular targets. Receptors that can bind ligand but do not produce a response are said to be uncoupled. The proteins that

TABLE 3.1 Four Major Families of Trimeric G Proteins

Family* Some Family Members

Subunits That Mediate Action Some Functions

I Gs α Activates adenylyl cyclase; activates Ca2+ channels Golf α Activates adenylyl cyclase in olfactory sensory neurons

II Gi α Inhibits adenylyl cyclase βγ Activates K+ channels

Go βγ Activates K+ channels; inactivates Ca2+ channels α and βγ Activates phospholipase C-β

Gt (transducin) α Activates cyclic GMP phosphodiesterase in vertebrate rod photoreceptors III Gq α Activates phospholipase C-β IV G12/13 α Activates Rho family monomeric GTPases (via Rho-GEF) to regulate the actin cytoskeleton

*Families are determined by amino acid sequence relatedness of the α subunits. Only selected examples are included. About 20 α subunits and 11 γ subunits have been described in humans. Alberts B, et al: Cell signaling. In Alberts B, et al: Molecular biology of the cell, ed 6, New York, 2015, Garland Science, p 846.

GTP

GTP

Water-soluble ligand

Nitric oxide (gas)

Guanylyl cyclase

Cyclic GMP

Protein kinase G

cGMP

cGMP

A B

FIG 3.38 Cyclic GMP (cGMP) is an important second messenger. A, It can be synthesized by enzyme-linked receptors that are activated by water-soluble ligands such as atrial natriuretic peptide. B, Nitric oxide is an important signaling molecule that is lipid soluble and can diffuse across the cell membrane. Nitric oxide binds to and stimulates the enzyme guanylyl cyclase to produce cGMP.

54 UNIT II Cellular Function

O Adenine

O

O

O

O

–O P

P O–O

CH2

CH2

H2O

OH

Phosphodiesterase

Uncoupling of receptors by GRKs

Generation of cyclic nucleotides (cAMP, cGMP)

P A

Internalization of receptors

B

Inactivation by phosphodiesterases

D

Degradation of receptors in lysosomes (down-regulation)

C

Inactivation by phosphatases

Phosphorylation of targets by kinases

E

O Adenine

OH OH

cAMP

AMP

FIG 3.39 A variety of mechanisms exist to inhibit receptor-mediated signaling cascades. A, Phosphorylation of the receptor by receptor kinases such as G-protein receptor kinases (GRKs) uncouples the enzyme from its intracellular cascade. B, Receptor internalization temporarily reduces the number of receptors displayed at the cell surface. C, Receptor degradation results in a long-term reduction in receptors (down-regulation). D, The cyclic nucleotide second messengers can be degraded by phosphodiesterase enzymes to stop the intracellular cascade. E, Phosphatase enzymes counteract the phosphorylating activities of kinases and inhibit the intracellular cascade.

Regulation of Cellular Growth and Proliferation In multicellular organisms such as humans, the growth and proliferation of cells and tissues must be strictly controlled to maintain a balance between cell birth rate and cell death rate. The system must be capable of rapidly increasing proliferation of a particular tissue to replace cells lost to injury and normal wear and tear while simultaneously inhibiting unwanted growth or proliferation of other cells. Special intercellular communication systems function to regulate the replication of individual cells in the body. Two important strategies of cell cycle control have been described. First, a variety of protein mitogens and growth factors are required in specific combinations for growth and proliferation of particular cell types. Second, cells respond to spatial signals from the extracellular matrix (from integrin receptors) and neighboring cells (from cell adhesion proteins) that indicate how much room is available. When conditions favor cell proliferation, the cell proceeds through the stages of the cell cycle (Fig. 3.41). Dormant cells can remain in G1 phase indefinitely (called G0). Cycling cells proceed through G1, S phase (synthesis), G2, M phase (mitosis), and cell division. S phase is character- ized by duplication of DNA and synthesis of intracellular components

in preparation for cell division. M phase, or mitosis, proceeds through six stages, beginning with prophase, in which the chromosomes condense and become visible, and ending with cytokinesis, when cell division is accomplished. The chromosomes of body cells are duplicated and distributed equally to the cell’s progeny when it divides by mitosis, such that each daughter cell receives an identical full set of 46 chromosomes. The stages of mitotic cell division are explained in Fig. 3.42. Mitosis is responsible for the proliferation of body cells in which little genetic variation is needed or desired. A more elaborate cell division process, meiosis, occurs in the germ cells (egg and sperm), where significant chromosomal rearrangements occur (see Chapter 6).

The cell cycle has been the subject of intense study in recent years because of its importance in cancer biology. Cancer cells continue to grow and divide unchecked, despite the lack of appropriate signals to stimulate them. Of particular interest are the events that prod the cell from its dormant state and cause it to begin the cycle. A simplified picture of a major component of this complex process is shown in Fig. 3.43. The Rb protein (or pRb) is of central importance in preventing a cell from proceeding through the cell cycle. The Rb protein functions to bind gene transcription factors called E2F so that they are unable to

CHAPTER 3 Cell Structure and Function 55

Cortisol Thyroid

Cytosolic receptor

Nuclear receptorDNA

Nucleus change in gene transcription

FIG 3.40 Lipid-soluble ligands, such as steroid hormones and gases, can diffuse across the cell membrane and interact with receptors located within the cell cytoplasm or nucleus. Thyroid hormone enters the cell through a carrier to interact with its intracellular receptor. When the ligand binds to its intracellular receptor, it forms a functional gene regulatory protein that affects the rate of transcription of its target genes. The response of the cell to intracellular ligands is generally slow and long lasting.

Restriction point

M phase

S phase

G1

G2

FIG 3.41 Events of the cell cycle. The cycle begins late in G1 when the cell passes a restriction point. The cell then proceeds systematically through the S phase (synthesis), G2, and M phase (mitosis).

To respond to a mitogen growth factor, a cell must have the cor- responding receptor on its cell surface. Many cells in the body synthesize and secrete mitogens, which then influence the proliferation of other cell types in a paracrine or endocrine fashion. Platelet-derived growth factor (PDGF) was one of the first mitogens to be discovered. It is secreted by platelets when they form blood clots in response to an injury. PDGF stimulates fibroblasts and smooth muscle cells in the damaged area to divide and replace cells lost to the injury. Numerous mitogens have been identified, and most cells require an appropriate combination of mitogen signals before they can enter the cell cycle. There are many signaling steps in the pathway from mitogen receptor to DNA activation. Somatic cells respond to GFs by increasing cell size, whereas stem cell populations undergo cell division. Thus the same signaling ligands may have different effects depending on cell type and conditions. Similar signaling pathways may also trigger cell death (apoptosis) when cells have to be reduced or removed during tissue development and remodeling. The processes of abnormal cellular proliferation and cancer are further detailed in Chapter 7. The process of apoptosis is described in Chapter 4.

KEY POINTS • Intercellular communication is accomplished by three principal means: (1)

gap junctions, which directly connect the cytoplasm of adjoining cells; (2) direct cell-to-cell surface contact; and (3) secretion of chemical mediators (ligands). Most ligands are water-soluble molecules that interact with receptors on the cell surface. These receptors are of three general types: ion channel linked, enzyme linked, and G-protein coupled.

• Binding of a ligand to a G-protein receptor controls the production of second messengers (cAMP, IP3, DAG, Ca

2+) within the target cell that initiate changes in cell function.

• Somatic cells divide by a process called mitosis in which daughter cells each receive an identical and complete set of 46 chromosomes.

• Cell replication normally requires specific extracellular mitogens that activate signaling systems within the cell. Cyclin proteins and Cdk alter the function of Rb protein, causing it to release transcription factors that begin the process of cell replication.

bind to DNA promoter regions and begin the processes of cell replication. The Rb protein can be induced to release the E2F transcription factors when appropriate mitogen signals arrive at the cell surface. These proliferation-promoting signals at the cell surface are transmitted to pRb by way of cyclin-dependent signaling pathways within the cell. Proteins called cyclins accumulate in the cell and then bind to and activate cyclin-dependent kinases (Cdk). The Cdk then phosphorylates pRb, changing its affinity for E2F so that it is released. The E2F then translocates to specific regions of DNA where it regulates more than 500 genes and promotes cell replication.

56 UNIT II Cellular Function

PROPHASE

Centromere

PROMETAPHASE

METAPHASE

Spindle poleCentriole

Microtubules

Random agitated chromosome

Cytoplasm

Aligned chromosomes

Microtubules attached to

centromeres

Polar tubules

ANAPHASE

Shortening microtubules

Elongating polar

tubules

Increasing distance between poles

TELOPHASE

Chromatids decondense

Cleavage furrow

CYTOKINESIS

Cleavage

Centrioles Cell membrane

Sister chromatids Nuclear membrane

Nucleus re-forms

Microtubules disappear

Polar tubule

UNDERSTANDING MITOSIS • PROPHASE—Chromatin slowly condenses into well-defined chromosomes that consist of two sister chromatids and a centromere. The mitotic spindle, a bipolar structure composed of microtubules and associated proteins, begins to form.

• PROMETAPHASE—Nuclear membrane disintegrates. Centrioles separate and polarize while spindle formation begins. Chromosomes respond with agitated movement.

• METAPHASE—Chromosomes align halfway between the spindle poles. Each is attached by its centromere to a microtubule that is also linked to the spindle pole.

• ANAPHASE—Centromeres divide, and the microtubule attached to each chromatid pulls it toward the pole. At the same time, the polar tubules elongate and the poles move farther apart.

• TELOPHASE—Separated daughter chromatids arrive at poles, and the microtubules disappear. Polar tubules continue to elongate, and the cell cleavage furrow appears. A nucleus re-forms at each pole.

• CYTOKINESIS—Cleavage completes the process, which results in two separate daughter cells.

FIG 3.42 Six stages of mitotic cell division. (Redrawn from Nichols FH, Zwelling E, editors: Maternal-newborn nursing: theory and practice, Philadelphia, 1997, Saunders, p 307.)

CHAPTER 3 Cell Structure and Function 57

Mitogens

Inhibitory signals

Accumulation of cyclins

Inhibit growth

Activation of G1 Cdk

Gene transcription

Start S phase

Phosphorylation of pRb

P

P P

pRb

Release of transcription factors (E2F)

FIG 3.43 The mechanism of initiation of cellular replication requires appropriate stimulation by extracellular growth factors that bind their complementary receptors on the cell surface. Activation of the receptor stimulates signaling pathways within the cell that increase cyclin proteins. The cyclins bind to cyclin-dependent kinases (Cdks) to form active enzyme complexes. The active cyclin-Cdk enzymes phosphorylate Rb protein (pRb), inducing it to release E2F transcription factors that initiate replication. In the absence of appropriate growth factor signals, the Rb protein functions to inhibit unwanted cell proliferation.

Detailed knowledge of cell physiology is essential to understanding disease processes. Cells are complex, membrane-bound units that perform a variety of functions necessary to the maintenance of life. The major cell components and their functions are summarized in Table 3.2. The cell membrane is an important cellular structure that protects the cell interior and mediates information transfer to and from the extracellular environment. Proteins embedded in the membrane lipid bilayer perform most of the membrane functions, including transduction of extracellular messages, membrane transport, electrical excitation, and cell-to-cell communication.

Human cells have several important intracellular organelles. These include the cytoskeleton, which organizes the intracellular compartment;

S U M M A R Y the nucleus, which holds the cell’s genetic material and directs the daily activities of the cell; the ER and the Golgi apparatus, which produce, package, and transport proteins and lipids to the plasma membrane and lysosomes; the lysosomes and peroxisomes, which perform the task of intracellular digestion of organic waste; and the mitochondria, which produce cellular energy in the form of ATP. The energy released by ATP hydrolysis is used by the cell to drive the many energetically unfavorable reactions needed to maintain cellular functions. Multicellular organisms have developed complex communication systems to control cell behavior, such as growth and differentiation into specialized cell types. Disruption of these cellular processes is at the root of pathophysiologic processes and disease.

TABLE 3.2 Structure and Function of Major Cellular Components

Cellular Structure Functions

Plasma membrane Protective barrier separates life from nonlife

Extracellular message transduction Transport of materials into and out

of cell Maintenance and transmission of

membrane potentials Cell-to-cell recognition, interaction

Cytoskeleton Maintenance of cell shape Cell movement Trafficking within cell

ATP, Adenosine triphosphate.

Cellular Structure Functions

Nucleus Protection of genetic material Regulation of cell type and function through

control of protein synthesis Endoplasmic reticulum Protein and lipid synthesis

Lipid metabolism and detoxification Golgi apparatus Protein and lipid modification and sorting

Transport of proteins and lipids to appropriate destinations

Lysosomes Hydrolytic breakdown of organic waste Peroxisomes Oxidative breakdown of organic waste Mitochondria Cellular energy production (ATP)

58 UNIT II Cellular Function

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Meisenberg G, Simmons WH: Glycolysis, tricarboxylic acid cycle, and oxidative phosphorylation. In Meisenberg G, Simmons WH, editors: Principles of medical biochemistry, ed 3, Philadelphia, 2012, Saunders, pp 347–373.

Pollard T, Earnshaw W: Cell biology, ed 2, Philadelphia, 2008, Saunders, p 332.

Cellular Electrical Potentials Alberts B, et al: Membrane transport of small molecules and the electrical

properties of membranes. In Alberts B, et al, editors: Molecular biology of the cell, ed 6, New York, 2015, Garland Science, pp 597–640.

Baker PF, Hodgkin AL, Shaw T: The effects of changes in internal ionic concentrations of the electrical properties of perfused giant axons. J Physiol 164:355–374, 1962.

Catterall WA: Structure and function of voltage-gated sodium channels at atomic resolution. Exp Physiol 99(1):35–51, 2014.

Hodgkin AL: The conduction of the nervous impulse, Liverpool, England, 1971, Liverpool University Press.

Hodgkin AL, Huxley AF: Currents carried by sodium and potassium ions through the membrane of the giant axon of Loligo. J Physiol 116:449–472, 1952.

Hodgkin AL, Huxley AF, Katz B: Measurement of current-voltage relations in the membrane of the giant axon of Loligo. J Physiol 116:424–448, 1952.

Hodgkin AL, Katz B: The effect of sodium ions on the electrical activity of the giant axon of the squid. J Physiol 108:37–77, 1949.

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the cell, ed 6, New York, 2015, Garland Science, pp 813–888. Dick FA, Rubin SM: Molecular mechanisms underlying RB protein function.

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59

4

Cell Injury, Aging, and Death Jacquelyn L. Banasik

K E Y Q U E S T I O N S • What are the usual cellular responses to reversible injury? • How are reversible and irreversible cellular injuries differentiated? • How do necrosis and apoptosis differ?

• To what kind of injuries are cells susceptible? • What are the usual physiologic changes of aging, and how are

these differentiated from disease?

C H A P T E R O U T L I N E Reversible Cell Injury, 59

Hydropic Swelling, 60

Intracellular Accumulations, 60

Cellular Adaptation, 63 Atrophy, 63

Hypertrophy, 63

Hyperplasia, 63

Metaplasia, 63

Dysplasia, 64

Irreversible Cell Injury, 64 Necrosis, 64

Apoptosis, 66

Etiology of Cellular Injury, 68 Ischemia and Hypoxic Injury, 68

Nutritional Injury, 70

Infectious and Immunologic Injury, 70

Chemical Injury, 72

Physical and Mechanical Injury, 72

Cellular Aging, 74 Cellular Basis of Aging, 74

Physiologic Changes of Aging, 75

Somatic Death, 75

http://evolve.elsevier.com/Banasik/pathophysiology/

Disease and injury are increasingly being understood as cellular and genomic phenomena. Although pathophysiologic processes are often presented in terms of systemic effects and manifestations, ultimately it is the cells that make up the systems that are affected. Even complex multisystem disorders such as cancer ultimately are the result of altera- tions in cell function. As the mysterious mechanisms of diseases are understood on the cellular and molecular levels, more specific methods of diagnosis, treatment, and prevention can be developed. This chapter presents the general characteristics of cellular injury, adaptation, aging, and death that underlie the discussions of systemic pathophysiologic processes presented in later chapters of this text.

Cells are confronted by many challenges to their integrity and survival and have efficient mechanisms for coping with an altered cellular environment. Cells respond to environmental changes or injury in three general ways: (1) when the change is mild or short lived, the cell may withstand the assault and completely return to normal. This is called a reversible cell injury. (2) The cell may adapt to a persistent but sublethal

injury by changing its structure or function. Generally, adaptation also is reversible. (3) Cell death may occur if the injury is too severe or prolonged. Cell death is irreversible and may occur by two different processes termed necrosis and apoptosis. Necrosis is cell death caused by external injury, whereas apoptosis is triggered by intracellular signaling cascades that result in regulated cell death. Necrosis is considered to be a pathologic process associated with significant tissue damage, whereas apoptosis may be a normal physiologic process in some instances and pathologic in others.

REVERSIBLE CELL INJURY Regardless of the cause, reversible injuries and the early stages of irrevers- ible injuries often result in cellular swelling and the accumulation of excess substances within the cell. These changes reflect the cell’s inability to perform normal metabolic functions because of insufficient cellular energy in the form of adenosine triphosphate (ATP) or dysfunction of

• Review Questions and Answers • Glossary (with audio pronunciations for selected terms) • Animations

• Case Studies • Key Points Review

60 UNIT II Cellular Function

is often associated with excessive intake of alcohol. Mechanisms whereby alcohol causes fatty liver remain unclear, but it is thought to result from direct toxic effects, as well as the preferential metabolism of alcohol instead of lipid (see Chapter 38 for a discussion of fatty liver). Lipids may also contribute to atherosclerotic diseases and accumulate in blood vessels, kidney, heart, and other organs. Fat-filled cells tend to compress cellular components to one side and cause the tissue to appear yellowish and greasy (Fig. 4.3). In several genetic disorders, the enzymes needed to metabolize lipids are impaired; these include Tay-Sachs disease and Gaucher disease, in which lipids accumulate in neurologic tissue.

Glycosaminoglycans (mucopolysaccharides) are large carbohydrate complexes that normally compose the extracellular matrix of connective tissues. Connective tissue cells secrete most of the glycosaminoglycan into the extracellular space, but a small portion remains inside the cell and is normally degraded by lysosomal enzymes. The mucopolysaccharidoses are a group of genetic diseases in which the enzymatic degradation of these molecules is impaired and they collect within the cell. Mental disabilities and connective tissue disorders are common findings.

Like other disorders of accumulation, excessive glycogen storage can be the result of inborn errors of metabolism, but a common cause is diabetes mellitus. Diabetes mellitus is associated with impaired cellular uptake of glucose, which results in high serum and urine glucose levels. Cells of the renal tubules reabsorb the excess filtered glucose and store it intracellularly as glycogen. The renal tubule cells also are a common site for abnormal accumulations of proteins. Normally, very little protein escapes the bloodstream into the urine. However, with certain disorders, renal glomerular capillaries become leaky and allow proteins to pass through them. Renal tubule cells recapture some of the escaped proteins through endocytosis, resulting in abnormal accumulation.

Cellular stress may lead to accumulation and aggregation of denatured proteins. The abnormally folded intracellular proteins may cause serious cell dysfunction and death if they are allowed to persist in the cell. A family of stress proteins (also called chaperone or heat-shock proteins) is responsible for binding and refolding aberrant proteins back into their correct three-dimensional forms (Fig. 4.4). If the chaperones are unsuccessful in correcting the defect, the abnormal proteins form complexes with another protein called ubiquitin. Ubiquitin targets the abnormal proteins to enter a proteosome complex, where they are digested into fragments that are less injurious to cells (see Fig. 4.4).

Finally, a variety of pigments and inorganic particles may be present in cells. Some pigment accumulations are normal, such as the accumulation

associated metabolic enzymes. Once the acute stress or injury has been removed, by definition of a reversible injury, the cell returns to its preinjury state.

Hydropic Swelling Cellular swelling attributable to accumulation of water—called hydropic swelling or oncosis—is the first manifestation of most forms of reversible cell injury. Hydropic swelling results from malfunction of the sodium– potassium (Na+–K+) pumps that normally maintain ionic equilibrium of the cell. Failure of the Na+–K+ pump results in accumulation of sodium ions within the cell, creating an osmotic gradient for water entry. Because Na+–K+ pump function is dependent on the presence of cellular ATP, any injury that causes insufficient energy production will result in hydropic swelling (Fig. 4.1). Hydropic swelling is character- ized by a large, pale cytoplasm; dilated endoplasmic reticulum; and swollen mitochondria. With severe hydropic swelling, the endoplasmic reticulum may rupture and form large water-filled vacuoles. Generalized swelling in the cells of a particular organ may cause the organ to increase in size and weight. Organ enlargement is indicated by the suffix -megaly (e.g., splenomegaly denotes an enlarged spleen, hepatomegaly denotes an enlarged liver).

Intracellular Accumulations Excess accumulations of substances in cells may result in cellular injury because the substances are toxic or provoke an immune response, or merely because they occupy space needed for cellular functions. In some cases, accumulations do not in themselves appear to be injurious, but rather are indicators of cell injury. Intracellular accumulations may be categorized as (1) excessive amounts of normal intracellular substances such as fat, (2) accumulation of abnormal substances produced by the cell because of faulty metabolism or synthesis, and (3) accumulation of pigments and particles that the cell is unable to degrade (Fig. 4.2).

Normal intracellular substances that tend to accumulate in injured cells include lipids, carbohydrates, glycogen, and proteins. Faulty metabolism of these substances within the cell results in excessive intracellular storage. In some cases, the enzymes required for breaking down a particular substance are absent or abnormal as a result of a genetic defect. In other cases, altered metabolism may be due to excessive intake, toxins, or other disease processes.

A common site of intracellular lipid accumulation is the liver, where many fats are normally stored, metabolized, and synthesized. Fatty liver

A B

FIG 4.1 Cellular swelling in kidney tubule epithelial cells. A, Normal kidney tubule with cuboidal cells. B, Early ischemic changes showing surface blebs and swelling of cells. (From Kumar V et al: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p 42. Photograph courtesy Drs. Neal Pinckard and M. A. Venkatachalam, University of Texas Health Sciences Center, San Antonio, TX.)

CHAPTER 4 Cell Injury, Aging, and Death 61

include calcium, tar, and mineral dusts such as coal, silica, iron, lead, and silver. Mineral dusts generally are inhaled and accumulate in lung tissue (Fig. 4.5). Inhaled dusts cause chronic inflammatory reactions in the lung, which generally result in destruction of pulmonary alveoli and capillaries and the formation of scar tissue. Over many years, the lung may become stiff and difficult to expand because of extensive scarring (see Chapter 23).

Deposits of calcium salts occur in conditions of altered calcium intake, excretion, or metabolism. Impaired renal excretion of phosphate

of melanin in tanned skin, whereas others signify pathophysiologic processes. Pigments may be produced by the body (endogenous) or may be introduced from outside sources (exogenous). In addition to melanin, the iron-containing substances hemosiderin and bilirubin are endogenous pigments that, when present in excessive amounts, indicate disease processes. Hemosiderin and bilirubin are derived from hemoglobin. Excessive amounts may indicate abnormal breakdown of red blood cells (RBCs), prolonged administration of iron, or the presence of hepatobiliary disorders. Inorganic particles that may accumulate

1, Abnormal metabolism

Normal cell

2, Defect in protein folding, transport

Protein mutation

Complex substrate Complex substrateEnzyme

Soluble products

4, Ingestion of indigestible materials

3, Lack of enzyme

Accumulation of endogenous materials

Accumulation of abnormal proteins

Accumulation of exogenous materials

Fatty liver

FIG 4.2 General mechanisms of intracellular accumulation: (1) abnormal metabolism as in fatty change in the liver, (2) mutations causing alterations in protein folding and transport so that defective proteins accumulate, (3) deficiency of critical enzyme responsible for lysosomal degradation, and (4) an inability to degrade phago- cytosed particles such as coal dust.

62 UNIT II Cellular Function

may result in the formation of calcium phosphate salts that are deposited in the tissues of the eye, heart, and blood vessels. Calcification of the heart valves may cause obstruction to blood flow through the heart or interfere with valve closing. Calcification of blood vessels may result in narrowing of vessels and insufficient blood flow to distal tissues. Dead and dying tissues often become calcified (filled with calcium salts) and appear as dense areas on x-ray films. For example, lung damage resulting from tuberculosis often is apparent as calcified areas, called tubercles.

With the exception of inorganic particles, the intracellular accumula- tions generally are reversible if the causative factors are removed.

FIG 4.3 Gross appearance of a fatty donor liver (A) compared with a normal nonfatty donor liver (B). (From Odze RD, Goldblum JR. Surgical pathology of the GI tract, liver, biliary tract, and pancreas, ed 2, St Louis, 2009, Elsevier.)

Accumulation of misfolded

proteins

Protein Stress (UV, heat, free radical injury, etc.)

Mutations Increased synthesis of chaperones to refold

Activation of the ubiquitin-proteasome pathway

Decreased translation of proteins to reduce debris

If too severe, activation of caspases

Apoptosis

Repair

Ubiquitin

Proteasome

Degradation of unfolded proteins

FIG 4.4 Roles of chaperone proteins in protein refolding and ubiquitin in protein degradation after stress- induced protein damage.

FIG 4.5 Accumulations of silicon dust in tissues of the lung. (From Kumar V et al: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p 690. Photograph courtesy Dr. John Goldeski, Brigham and Women’s Hospital, Boston, MA.)

KEY POINTS • Hydropic swelling is an early indicator of cell injury. It results from Na+–K+

pump dysfunction at the cell membrane. • Intracellular accumulations of abnormal endogenous or exogenous particles

indicate a disorder of cellular metabolism. • Damage from accumulation of abnormal intracellular protein is limited by

chaperone proteins that attempt to refold the protein into its correct shape and by the ubiquitin–proteosome system that digests targeted proteins into fragments.

CHAPTER 4 Cell Injury, Aging, and Death 63

The biochemical pathways that result in cellular atrophy are imper- fectly known; however, two pathways for protein degradation have been implicated. The first is the previously mentioned ubiquitin–proteosome system, which degrades targeted proteins into small fragments (see Fig. 4.4). The second involves the lysosomes that may fuse with intracellular structures, leading to hydrolytic degradation of the components (autophagy). Certain substances apparently are resistant to degradation and remain in the lysosomal vesicles of atrophied cells. For example, lipofuscin is an age-related pigment that accumulates in residual vesicles in atrophied cells, giving them a yellow-brown appearance.

Hypertrophy Hypertrophy is an increase in cell mass accompanied by an augmented functional capacity. Cells hypertrophy in response to increased physiologic or pathophysiologic demands. Cellular enlargement results primarily from a net increase in cellular protein content. Like the other adaptive responses, hypertrophy subsides when the increased demand is removed; however, the cell may not entirely return to normal because of persistent changes in connective tissue structures. Organ enlargement may be a result of both an increase in cell size (hypertrophy) and an increase in cell number (hyperplasia). For example, an increase in skeletal muscle mass and strength in response to repeated exercise is primarily the result of hypertrophy of individual muscle cells, although some increase in cell number is also possible because muscle stem cells (satellite cells) are able to divide. Physiologic hypertrophy occurs in response to a variety of trophic hormones in sex organs—the breast and uterus, for example. Certain pathophysiologic conditions may place undue stress on some tissues, causing them to hypertrophy. Liver enlargement in response to bodily toxins and cardiac muscle enlargement in response to high blood pressure (Fig. 4.7) represent hyperplastic and hypertrophic adaptations to pathologic conditions. Hypertrophic adaptation is particularly important for cells, such as differentiated muscle cells, that are unable to undergo mitotic division.

Hyperplasia Cells that are capable of mitotic division generally increase their functional capacity by increasing the number of cells (hyperplasia) as well as by hypertrophy. Hyperplasia usually results from increased physiologic demands or hormonal stimulation. Persistent cell injury also may lead to hyperplasia. Examples of demand-induced hyperplasia include an increase in RBC number in response to high altitude and liver enlargement in response to drug detoxification. Trophic hormones induce hyperplasia in their target tissues. Estrogen, for example, leads to an increase in the number of endometrial and uterine stromal cells. Dysregulation of hormones or growth factors can result in pathologic hyperplasia, such as that which occurs in thyroid or prostate enlargement.

Chronic irritation of epithelial cells often results in hyperplasia. Calluses and corns, for example, result from chronic frictional injury to the skin. The epithelium of the bladder commonly becomes hyper- plastic in response to the chronic inflammation of cystitis.

Metaplasia Metaplasia is the replacement of one differentiated cell type with another. This most often occurs as an adaptation to persistent injury, with the replacement cell type better able to tolerate the injurious stimulation. Metaplasia is fully reversible when the injurious stimulus is removed. Metaplasia often involves the replacement of glandular epithelium with squamous epithelium. Chronic irritation of the bronchial mucosa by cigarette smoke, for example, leads to the conversion of ciliated columnar epithelium to stratified squamous epithelium. Metaplastic cells generally remain well differentiated and of the same tissue type, although cancerous

CELLULAR ADAPTATION The cellular response to persistent, sublethal stress reflects the cell’s efforts to adapt. Cellular stress may be due to an increased functional demand or a reversible cellular injury. Although the term adaptation implies a change for the better, in some instances an adaptive change may not be beneficial. The common adaptive responses are atrophy (decreased cell size), hypertrophy (increased cell size), hyperplasia (increased cell number), metaplasia (conversion of one cell type to another), and dysplasia (disorderly growth) (Fig. 4.6). Each of these changes is potentially reversible when the cellular stress is relieved.

Atrophy Atrophy occurs when cells shrink and reduce their differentiated functions in response to a variety of normal and injurious factors. The general causes of atrophy may be summarized as (1) disuse, (2) denervation, (3) ischemia, (4) nutrient starvation, (5) interruption of endocrine signals, (6) and persistent cell injury. Apparently, atrophy represents an effort by the cell to minimize its energy and nutrient consumption by decreasing the number of intracellular organelles and other structures.

A common form of atrophy is the result of a reduction in functional demand, sometimes called disuse atrophy. For example, immobilization by bed rest or casting of an extremity results in shrinkage of skeletal muscle cells. On resumption of activity, the tissue resumes its normal size. Denervation of skeletal muscle results in a similar decrease in muscle size caused by loss of nervous stimulation. Inadequate blood supply to a tissue is known as ischemia. If the blood supply is totally interrupted, the cells will die, but chronic sublethal ischemia usually results in cell atrophy. The heart, brain, kidneys, and lower leg are common sites of ischemia. Atrophic changes in the lower leg attributable to ischemia include thin skin, muscle wasting, and hair loss. Atrophy can be a consequence of chronic nutrient starvation, whether the result of poor intake, absorption, or distribution to the tissues. Many glandular tissues throughout the body depend on growth-stimulating (trophic) signals to maintain size and function. For example, the adrenal cortex, thyroid, and gonads are maintained by trophic hormones from the pituitary gland and will atrophy in their absence. Atrophy that results from persistent cell injury is most commonly related to chronic inflam- mation and infection.

Normal

Hypertrophy (increased cell size)

Metaplasia (conversion of one cell

type to another)

Atrophy (decreased cell size)

Hyperplasia (increased cell number)

Dysplasia (disorderly growth)

FIG 4.6 The adaptive cellular responses of atrophy, hypertrophy, hyperplasia, metaplasia, and dysplasia.

64 UNIT II Cellular Function

IRREVERSIBLE CELL INJURY Pathologic cellular death occurs when an injury is too severe or prolonged to allow cellular adaptation or repair. Two different processes may contribute to cell death in response to injury: necrosis and apoptosis. Necrosis usually occurs as a consequence of ischemia or toxic injury and is characterized by cell rupture, spilling of contents into the extracel- lular fluid, and inflammation. Apoptosis (from a Greek word meaning falling off, as in leaves from a tree) occurs in response to injury that does not directly kill the cell but triggers intracellular cascades that activate a cellular suicide response. Apoptotic cells generally do not rupture and are ingested by neighboring cells with minimal disruption of the tissue and without inflammation. Apoptosis is not always a pathologic process and occurs as a necessity of development and tissue remodeling.

Necrosis Necrotic cells demonstrate typical morphologic changes, including a shrunken (pyknotic) nucleus that is subsequently degraded (karyolysis), a swollen cell volume, dispersed ribosomes, and disrupted plasma and organelle membranes (Fig. 4.8). The disruption of the permeability barrier of the plasma membrane appears to be a critical event in the death of the cell.

Localized injury or death of tissue is generally reflected in the entire system as the body attempts to remove dead cells and works to com- pensate for loss of tissue function. Several manifestations indicate that the system is responding to cellular injury and death. A general inflam- matory response is often present, with general malaise, fever, increased heart rate, increased white blood cell (WBC) count, and loss of appetite. With the death of necrotic cells, intracellular contents are released and often find their way into the bloodstream. The presence of specific cellular proteins in the blood is used as an indicator of the location and extent of cellular death. For example, an elevated serum amylase level indicates pancreatic damage, and an elevated creatine kinase (MB isoenzyme) or cardiac troponin level indicates myocardial damage. The location of pain caused by tissue destruction may also aid in the diagnosis of cellular death.

Four different types of tissue necrosis have been described: coagulative, liquefactive, fat, and caseous (Fig. 4.9). They differ primarily in the type of tissue affected. Coagulative necrosis is the most common. Manifesta- tions of coagulative necrosis are the same, regardless of the cause of cell death. In general, the steps leading to coagulative necrosis may be summarized as follows: (1) ischemic cellular injury, leading to (2) loss of the plasma membrane’s ability to maintain electrochemical gradients, which results in (3) an influx of calcium ions and mitochondrial dysfunc- tion, and (4) degradation of plasma membranes and nuclear structures (Fig. 4.10). The area of coagulative necrosis is composed of denatured proteins and is relatively solid. The coagulated area is then slowly dissolved by proteolytic enzymes, and the general tissue architecture is preserved for a relatively long time (weeks). This is in contrast to liquefactive necrosis.

When the dissolution of dead cells occurs very quickly, a liquefied area of lysosomal enzymes and dissolved tissue may result and form an abscess or cyst. This type of necrosis, called liquefactive necrosis, may be seen in the brain, which is rich in degradative enzymes and contains little supportive connective tissue. Liquefaction may also result from a bacterial infection that triggers a localized collection of WBCs. The phagocytic WBCs contain potent degradative enzymes that may completely digest dead cells, resulting in liquid debris.

Fat necrosis refers to death of adipose tissue and usually results from trauma or pancreatitis. The process begins with the release of activated digestive enzymes from the pancreas or injured tissue. The

transformations can occur. Some cancers of the lung, cervix, stomach, and bladder appear to derive from areas of metaplastic epithelium.

Dysplasia Dysplasia refers to the disorganized appearance of cells because of abnormal variations in size, shape, and arrangement. Dysplasia occurs most frequently in hyperplastic squamous epithelium, but it may also be seen in the mucosa of the intestine. Dysplasia probably represents an adaptive effort gone astray. Dysplastic cells have significant potential to transform into cancerous cells and are usually regarded as preneoplastic lesions. (See Chapter 7 for a discussion of cancer.) Dysplasia that is severe and involves the entire thickness of the epithelium is called carcinoma in situ. Mild forms of dysplasia may be reversible if the inciting cause is removed.

A

B

FIG 4.7 A, Hypertrophy of cardiac muscle in the left ventricular chamber. B, Compare with the thickness of the normal left ventricle. This is an example of cellular adaptation to an increased cardiac workload. (From Kumar V et al: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p 33.)

KEY POINTS • Adaptive cellular responses indicate cellular stress caused by altered

functional demand or chronic sublethal injury. • Hypertrophy and hyperplasia generally result from increased functional

demand. Atrophy results from decreased functional demand or chronic ischemia. Metaplasia and dysplasia result from persistent injury.

CHAPTER 4 Cell Injury, Aging, and Death 65

tissue, it is described as dry gangrene, wet gangrene, or gas gangrene. Dry gangrene is a form of coagulative necrosis characterized by blackened, dry, wrinkled tissue that is separated from adjacent healthy tissue by an obvious line of demarcation (see Fig. 4.9A). It generally occurs only on the extremities. Liquefactive necrosis may result in wet gangrene, which is typically found in internal organs, appears cold and black, and may be foul smelling because of the invasion of bacteria. Rapid spread of tissue damage and the release of toxins into the bloodstream make wet gangrene a life-threatening problem. Gas gangrene is characterized by the formation of bubbles of gas in damaged tissue. Gas gangrene is the result of infection of necrotic tissue by anaerobic bacteria of the genus Clostridium. These bacteria produce toxins and degradative enzymes that allow the infection to spread rapidly through the necrotic tissue. Gas gangrene may be fatal if not managed rapidly and aggressively.

enzymes attack the cell membranes of fat cells, causing release of their stores of triglycerides. Pancreatic lipase can then hydrolyze the triglyc- erides to free fatty acids and glycerol, which precipitate as calcium soaps (saponification). Fat necrosis appears as a chalky white area of tissue.

Caseous necrosis is characteristic of lung tissue damaged by tuber- culosis. The areas of dead lung tissue are white, soft, and fragile, resembling clumpy cheese. Dead cells are walled off from the rest of the lung tissue by inflammatory WBCs. In the center, the dead cells lose their cellular structure but are not totally degraded. Necrotic debris may persist indefinitely.

Gangrene is a term used to describe cellular death involving a large area of tissue. Gangrene usually results from interruption of the major blood supply to a particular body part, such as the toes, leg, or bowel. Depending on the appearance and subsequent infection of the necrotic

Apoptotic body with intact membrane

Condensation of chromatin

Membrane blebs

Phagocyte

Phagocytosis of apoptotic cells and fragments

Reversible injury

Progressive injury

Inflammation

Recovery

NORMAL CELLNORMAL CELL

NECROSIS

APOPTOSIS

Swelling of endoplasmic reticulum and mitochondria Membrane blebs

Amorphous densities in mitochondria

Breakdown of plasma membrane, organelles and nucleus; leakage of contents

Myelin figure

FIG 4.8 Comparison of cellular changes in necrosis and apoptosis.

66 UNIT II Cellular Function

elicit inflammation. Apoptosis is not a rare event; large numbers of cells are continually undergoing programmed cell death as tissues remodel. During fetal development, for example, more than half of the nerve cells that form undergo apoptosis. It is estimated that more than 95% of the T lymphocytes that are generated in the bone marrow are induced to undergo apoptosis after reaching the thymus. These are normal physiologic processes that regulate normal system function.

Apoptosis The number of cells in tissues is tightly regulated by controlling the rate of cell division and the rate of cell death. If cells are no longer needed, they activate a cellular death pathway resulting in regulated cell death. In contrast to necrosis, which is messy and results in inflam- mation and collateral tissue damage, apoptosis is tidy and does not

B

C

D

A

FIG 4.9 The four primary types of tissue necrosis. A, Coagulative. B, Liquefactive. C, Fat. D, Caseous. (A, From Crowley L: Introduction to human disease, ed 4, Sudbury, MA, 1996, Jones and Bartlett, www.jbpub. com. Reprinted with permission. B–D, From Kumar V et al: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, pp 43–44.)

CHAPTER 4 Cell Injury, Aging, and Death 67

impaired. Apoptosis is now recognized as a primary factor in diseases such as heart failure (Chapter 19) and dementia (Chapter 45). The mechanisms regulating apoptosis are complex, and only major concepts are included here.

Environmental or extrinsic signals may induce apoptosis. Apoptosis may be triggered by withdrawal of “survival” signals that normally suppress the apoptotic pathways. Normal cells require a variety of signals from neighboring cells and from the extracellular matrix in order to stay alive (Fig. 4.11). If these contacts or signals are removed, the cell

Apoptosis also has been implicated in pathologic cell death and disease. For example, it has been estimated that the area of tissue death after a myocardial infarction (heart attack) is about 20% necrotic and 80% apoptotic. It is difficult to measure the degree of apoptotic cell death because neighboring cells rapidly ingest their apoptotic neighbors, and few are ever present in the tissue but the rates are high. Death of cancer cells in response to radiation or chemotherapy is believed to be primarily caused by apoptotic mechanisms. When the rate of apoptosis is greater than the rate of cell replacement, tissue or organ function may be

Injurious agent

Mitochondrion

ATPasePhospholipase Protease

Activation of cellular enzymes

Mitochondrial permeability

transition

Membrane damage

Nuclear damage

ATP

Elevated Ca2+ in cytosol

Smooth ER

Extracellular Ca2+

Ca2+

Ca2+

Phospholipids Disruption

of membrane and cytoskeletal

proteins

Endo- nuclease

Ca2+

Ca2+

Ca2+

FIG 4.10 Cellular injury as a consequence of intracellular calcium overload.

Survival

Matrix proteins

ApoptosisA B FIG 4.11 Each cell displays a set of receptors that enable it to respond to extracellular signals that control growth, differentiation, and survival. A, Extracellular signals are provided by the neighboring cells, secreted signaling molecules, and the extracellular matrix. B, Withdrawal of these survival signals induces the cell to initiate apoptosis.

68 UNIT II Cellular Function

ETIOLOGY OF CELLULAR INJURY Cellular injury and death result from a variety of cellular assaults, including lack of oxygen and nutrients, infection and immune responses, chemicals, and physical and mechanical factors. The extent of cell injury and death depends in part on the duration and severity of the assault and in part on the prior condition of the cells. Well-nourished and somewhat adapted cells may withstand the injury better than cells that are poorly nourished or not adapted.

Ischemia and Hypoxic Injury Living cells must receive a continuous supply of oxygen to produce sufficient ATP to power energy-requiring functions. The lack of oxygen (hypoxia) results in power failure within the cell. Tissue hypoxia is most often caused by ischemia, or the interruption of blood flow to an area, but it may also result from heart failure, lung disease, and RBC disorders. Ischemia is the most common cause of cell injury in clinical medicine and injures cells faster than hypoxia alone. Faster injury occurs because

death cascade is activated. A second mechanism of triggering apoptosis involves extracellular signals, such as the Fas ligand, that bind to the cell and trigger the death cascade through activation of “death receptors” (Fig. 4.12).

Apoptosis can also be triggered by internal pathways. Cells have ways to monitor their condition and usefulness. When excessive, irreparable damage occurs to the cell’s DNA or other vital structures, growth and division stall for a while to permit repair. If the damage is too great, the cell can trigger its own death. Mitochondrial damage with leakage of cytochrome c into the cytoplasm is a critical activator of the intrinsic apoptotic pathway. This pathway is governed in part by a protein called p53. The amount of p53 in a cell is normally quite low but increases in response to cellular DNA damage. If high levels of p53 are sustained, apoptosis will occur. Thus p53 is important in preventing the proliferation of cells with damaged DNA. A large number of cancers (50%) are associated with a mutation in the P53 gene, which allows cancer cells to escape this monitoring system.

Regardless of the initiating event, apoptosis involves numerous intracellular signals and enzymes (Fig. 4.13). A family of enzymes called caspases is the main component of the proteolytic cascade that degrades key intracellular structures leading to cell death. The caspases are proenzymes that are activated in a cascade. Activation of a few initiator caspases at the beginning of the cascade results in a rapid domino effect of caspase activation. Some caspases cleave key proteins, such as the nuclear lamina, to destroy the nuclear envelope, whereas others activate still more enzymes that chop up the DNA. All of this destruction requires cellular energy and is contained within an intact plasma membrane, and the cell remnants are then assimilated by their neighbors. Neighboring cells are prompted to ingest apoptotic cells, because a phospholipid that is normally located only on the cytoplasmic side of a healthy cell (phosphatidylserine) flips to the outside of the lipid bilayer. This membrane lipid signals neighbors and tissue macrophages to bind and assimilate the cell components and suppresses the inflammatory response that normally accompanies phagocytosis.

Apoptosis

Nuclear fragmentation

Adaptor

Active caspase

Target cell

Fas ligand

Fas receptor

Adaptor

Inactive pro- caspase-8A B

C

FIG 4.12 Induction of apoptosis by Fas ligand. A, Target cell binds to Fas ligand on a signaling cell. B, Active Fas receptors organize and activate caspases. C, The caspases degrade the nucleus and trigger cell death.

KEY POINTS • Necrosis occurs when the injury is too severe or prolonged to allow adaptation

and is usually a consequence of disrupted blood supply. • Local and systemic indicators of necrotic cell death include pain, elevated

serum enzyme levels, inflammation (fever, elevated white blood cell [WBC] count, malaise), and loss of function.

• Different tissues exhibit necrosis of different types: heart (coagulative), brain (liquefactive), lung (caseous), and pancreas (fat).

• Gangrene refers to a large area of necrosis that may be described as dry, wet, or gas gangrene. Gas gangrene and wet gangrene may be rapidly fatal.

• Apoptosis is cell death resulting from activation of intracellular signaling cascades. Apoptosis is tidy and not usually associated with systemic manifestations of inflammation. Apoptosis requires adequate amounts of adenosine triphosphate (ATP) be present in the cell.

CHAPTER 4 Cell Injury, Aging, and Death 69

(2) formation of reactive oxygen molecules (free radicals), and (3) subsequent inflammation.

Restoration of blood flow to ischemic cells bathes them in a fluid high in calcium ions at a time when their ATP stores are depleted and they are unable to control ion flux across the cell membrane. Accumula- tion of calcium ions in the cytoplasm can trigger apoptosis or activate enzymes that degrade lipids in the membrane (lipid peroxidation).

The ischemic episode also primes cells for abnormal generation of reactive oxygen molecules, such as superoxide (O2−), peroxide (H2O2), and hydroxyl radicals (OH−). These reactive oxygen molecules are free radicals that have an unpaired electron in an outer orbital. They steal hydrogen atoms and form abnormal molecular bonds. Molecules that react with free radicals may be converted to free radicals themselves, continuing the destructive cascade. Reactive oxygen species damage cell membranes, denature proteins, and disrupt cell chromosomes. Oxygen free radicals also have been linked to initiation of the inflammatory cascade.

Ischemia primes cells for the generation of oxygen radicals by allowing the buildup of ATP precursors, such as adenosine diphosphate and pyruvate, during the period of hypoxia. When oxygen supply is reestablished, a disorganized burst of high-energy electrons partially reduces oxygen and forms oxygen radicals. The ischemia–reperfusion

ischemia not only disrupts the oxygen supply but also allows metabolic wastes to accumulate and deprives the cell of nutrients for glycolysis. The cellular events that follow oxygen deprivation are shown in Fig. 4.14. Decreased oxygen delivery to the mitochondria causes ATP produc- tion in the cell to stall and ATP-dependent pumps, including the Na+–K+ and Ca2+ pumps, to fail. Sodium accumulation within the cell creates an osmotic gradient favoring water entry, resulting in hydropic swelling. Excess intracellular calcium collects in the mitochondria, further interfering with mitochondrial function. A small amount of ATP is produced by anaerobic glycolytic pathways, which metabolize cellular stores of glycogen. The pyruvate end products of glycolysis accumulate and are converted to lactate, causing cellular acidification. Lactate can escape into the bloodstream, resulting in lactic acidosis, which can be detected by laboratory tests. Cellular proteins and enzymes become progressively more dysfunctional as the pH falls. Up to a point, ischemic injury is reversible, but when the plasma, mitochondrial, and lysosomal membranes are critically damaged, cell death ensues.

Cell death resulting from ischemia may be slow to develop, generally taking many minutes to hours. In fact, most cellular damage occurs after the blood supply to the tissues has been restored—a so-called reperfusion injury. Ischemia–reperfusion is a complex phenomenon, but three critical components have been identified: (1) calcium overload,

Phagocyte

MITOCHONDRIAL (INTRINSIC) PATHWAY

DEATH RECEPTOR (EXTRINSIC) PATHWAY

Mitochondria

Receptor-ligand interactions • Fas • TNF receptor

Cell injury • Growth factor withdrawal • DNA damage (by radiation, toxins, free radicals) • Protein misfolding (ER stress)

Initiator caspases

Initiator caspases

Cytochrome c and other

pro-apoptotic proteins

Regulators (BCL-2, BCL-X)

Executioner caspases

Adapter proteins

Breakdown of cytoskeleton

Endonuclease activation

Membrane bleb Ligands for phagocytic cell receptors

Apoptotic body

Nuclear fragmentation

BCL-2 family sensors

BCL-2 family effectors (BAX, BAK)

FIG 4.13 Schematic of the events of apoptosis. Numerous triggers can initiate apoptosis through intrinsic cell injury pathways (mitochondrial), such as withdrawal of survival factors, various cell injuries, and protein overload or misfolding; or through extrinsic cell injury pathways (death receptors), such as binding to Fas or tumor necrosis factor receptors. A number of intracellular regulatory proteins may inhibit or promote the activation of caspases, which, when activated, begin the process of cellular degradation and apoptotic cell fragmentation. Fragments are internalized by phagocytic cells.

70 UNIT II Cellular Function

glucose levels. An excess of caloric intake above metabolic use produces overweight and obesity syndromes. Excess body fat can be estimated by measuring the ratio of body weight (in kilograms) to height (in meters squared) to derive the body mass index (BMI). A BMI greater than 25 kg/m2 imparts a health risk, and a BMI greater than 30 kg/m2 is considered indicative of obesity. Numerous health problems are associated with excess body fat, including heart and blood vessel disease, musculoskeletal strain, diabetes, hypertension, and gallbladder disease. Metabolism and obesity are explored in Chapter 42.

Infectious and Immunologic Injury Bacteria and viruses are common infectious agents that may injure cells in a variety of ways. The virulence of a particular biological agent depends on its ability to gain access to the cell and its success in altering cellular functions. (See Chapter 8 for a detailed discussion of infectious processes.) Some of the injurious effects are directly from the biological agent, but added injury may be done indirectly by triggering the body’s immune response.

Most bacteria do not gain entry into the cell and so accomplish their injurious effects from the outside. (Notable exceptions include Mycobacterium tuberculosis, Shigella, Legionella, Salmonella, and Chla- mydia.) Some bacteria produce and secrete powerful destructive enzymes that digest cellular membranes and connective tissues. For example, collagenase and lecithinase are produced by Clostridium perfringens. Other bacteria produce exotoxins, which interfere with specific cellular functions when released from the bacterium. Clostridium botulinum and Clostridium tetani, for example, produce life-threatening toxins that disrupt normal neuromuscular transmission. Cholera and diphtheria are well-known examples of exotoxin-related diseases. Most exotoxins are proteins and are generally susceptible to destruction by extremes of heat. Certain gram-negative bacteria (e.g., Escherichia coli, Klebsiella pneumoniae) contain another type of toxin, endotoxin, in their cell wall. When bacteria are killed, the endotoxin is released, causing fever, malaise, and even circulatory shock.

The indirect cellular injury attributable to the bacteria-evoked immune response may be more damaging than the direct effects of the

event frequently is followed by a generalized inflammatory state that may lead to ongoing cellular and organ damage for days and weeks after the initial event. WBCs recruited to the area release enzymes and other chemicals that further damage the cells in the area. (Mecha- nisms and causes of ischemic tissue injury are described further in Chapter 20.)

Nutritional Injury Adequate amounts of fats, carbohydrates, proteins, vitamins, and minerals are essential for normal cellular function. Most of these essential nutrients must be obtained from external sources because the cell is unable to manufacture them. The cell is unable to synthesize many of the 20 amino acids needed to form the proteins of the body. Likewise, most vitamins and minerals must be obtained from exogenous sources. Cell injury results from deficiencies as well as excesses of essential nutrients.

Certain cell types are more susceptible to injury from particular nutritional imbalances. Iron deficiency, for example, primarily affects RBCs, whereas vitamin D deficiency affects bones. All cell types must receive glucose for energy, as well as fatty acid and amino acid building blocks to synthesize and repair cellular components. Nutritional deficien- cies result from poor intake, altered absorption, impaired distribution by the circulatory system, or inefficient cellular uptake. Common causes of malnutrition include (1) poverty, (2) chronic alcoholism, (3) acute and chronic illness, (4) self-imposed dietary restrictions, and (5) malabsorption syndromes. Vitamin deficiencies are common even in industrialized countries because of pervasive use of processed foods. Some examples of vitamin deficiency disorders are shown in Table 4.1. Deficiencies of minerals, especially iron, also are common (Table 4.2).

Nutritional excesses primarily result from excessive intake, although deficient cellular uptake by one cell type may contribute to excess nutrient delivery to other cell types. For example, in the condition of diabetes mellitus, some cell types have deficient receptors for insulin-dependent glucose uptake, which causes excessive amounts of glucose to remain in the bloodstream. As a result, cells that do not require insulin to take in glucose, such as neurons, may have abnormally high intracellular

O2 Cytosolic Ca2+

Phospholipase activation

Reactive oxygen species

Protease activation

ATP

Phospholipid degradation

Lipid peroxidation

Phospholipid loss

Lipid breakdown products

Cytoskeletal damage

Phospholipid reacylation/ synthesis

Membrane damage

FIG 4.14 Mechanisms of ischemia-induced cell injury and membrane damage. Loss of cell membrane integrity is a critical event in necrosis.

CHAPTER 4 Cell Injury, Aging, and Death 71

TABLE 4.1 Vitamins: Major Functions and Deficiency Syndromes

Vitamin Functions Deficiency Syndromes

Fat Soluble Vitamin A A component of visual pigment Night blindness, xerophthalmia, blindness

Maintenance of specialized epithelia Squamous metaplasia Maintenance of resistance to infection Vulnerability to infection, particularly measles

Vitamin D Facilitates intestinal absorption of calcium and phosphorus and mineralization of bone

Rickets in children Osteomalacia in adults

Vitamin E Major antioxidant; scavenges free radicals Spinocerebellar degeneration Vitamin K Cofactor in hepatic carboxylation of procoagulants—factors II

(prothrombin), VII, IX, and X; and protein C and protein S Bleeding diathesis

Water-Soluble Vitamin B1 (thiamine) As pyrophosphate, is coenzyme in decarboxylation reactions Dry and wet beriberi, Wernicke syndrome, Korsakoff syndrome Vitamin B2 (riboflavin) Converted to coenzymes flavin mononucleotide and flavin adenine

dinucleotide, cofactors for many enzymes in intermediary metabolism

Ariboflavinosis, cheilosis, stomatitis, glossitis, dermatitis, corneal vascularization

Niacin Incorporated into NAD and NAD phosphate; involved in a variety of redox reactions

Pellagra—“three D’s”: dementia, dermatitis, diarrhea

Vitamin B6 (pyridoxine) Derivatives serve as coenzymes in many intermediary reactions Cheilosis, glossitis, dermatitis, peripheral neuropathy Vitamin B12 Required for normal folate metabolism and DNA synthesis Megaloblastic pernicious anemia and degeneration of

posterolateral spinal cord tractsMaintenance of myelinization of spinal cord tracts Vitamin C Serves in many oxidation-reduction (redox) reactions and

hydroxylation of collagen Scurvy

Folate Essential for transfer and use of 1-carbon units in DNA synthesis Megaloblastic anemia, neural tube defects Pantothenic acid Incorporated in coenzyme A No nonexperimental syndrome recognized Biotin Cofactor in carboxylation reactions No clearly defined clinical syndrome

From Kumar V et al: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p 442. NAD, Nicotinamide adenine dinucleotide.

TABLE 4.2 Selected Trace Elements and Deficiency Syndromes

Element Function Basis of Deficiency Clinical Features

Zinc Component of enzymes, principally oxidases Inadequate supplementation in artificial diets Interference with absorption by other dietary

constituents Inborn error of metabolism

Rash around eyes, mouth, nose, and anus called acrodermatitis enteropathica

Anorexia and diarrhea Growth retardation in children Depressed mental function Depressed wound healing and immune response Impaired night vision Infertility

Iron Essential component of hemoglobin as well as a number of iron-containing metalloenzymes

Inadequate diet Chronic blood loss

Hypochromic microcytic anemia

Iodine Component of thyroid hormone Inadequate supply in food and water Goiter and hypothyroidism Copper Component of cytochrome c oxidase,

dopamine β-hydroxylase, tyrosinase, lysyl oxidase, and unknown enzymes involved in cross-linking collagen

Inadequate supplementation in artificial diet Interference with absorption

Muscle weakness Neurologic defects Abnormal collagen cross-linking

Fluoride Mechanism unknown Inadequate supply in soil and water Inadequate supplementation

Dental caries

Selenium Component of glutathione peroxidase Antioxidant with vitamin E

Inadequate amounts in soil and water Myopathy Cardiomyopathy (Keshan disease)

From Kumar V et al: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p 443.

infectious agent. WBCs secrete many enzymes and chemicals meant to destroy the invading organism, including histamines, kinins, complement, proteases, lymphokines, and prostaglandins. Normal body cells may be exposed to these injurious chemicals because they are too close to the site of immunologic battle. Immune cells are particularly adept at

producing free radicals, which can attack host cell membranes and induce significant cell injury.

Viruses are small pieces of genetic material that are able to gain entry into the cell. They may be regarded as intracellular parasites that use the host cell’s metabolic and synthetic machinery to survive and

72 UNIT II Cellular Function

failure. In high doses, acetaminophen, a commonly used analgesic, may have similar toxic effects on the liver.

Many toxins are inherently reactive and do not require metabolic activation to exert their effects. Common examples are heavy metals (e.g., lead and mercury), toxic gases, corrosives, and antimetabolites. Some toxins have an affinity for a particular cell type or tissue, whereas others exert widespread systemic effects. For example, carbon monoxide binds tightly and selectively to hemoglobin, preventing the RBC from carrying sufficient oxygen. Lead poisoning, however, has widespread effects, including effects on nervous tissue, blood cells, and the kidney. Extremely acidic or basic chemicals are directly corrosive to cellular structures. Certain chemicals interfere with normal metabolic processes of the cell. Some of these antimetabolites have been utilized in the form of cytotoxic agents for the management of cancer (Chapter 7).

Physical and Mechanical Injury Injurious physical and mechanical factors include extremes of tem- perature, abrupt changes of atmospheric pressure, mechanical deforma- tion, electricity, and ionizing radiation.

Extremes of cold result in the hypothermic injury known as frostbite. Before actual cellular freezing, severe vasoconstriction and increased blood viscosity may result in ischemic injury. With continued exposure to cold, a rebound vasodilatory response may occur, leading to intense swelling and peripheral nerve damage. The cytoplasmic solution may freeze, resulting in the formation of intracellular ice crystals and rupture of cellular components. Frostbite generally affects the extremities, ears, and nose and is often complicated by gangrenous necrosis.

Extremes of heat result in hyperthermic injury or burns. High temperatures cause microvascular coagulation and may accelerate metabolic processes in the cell. Burns result from direct tissue destruction by high temperatures and are classified according to the degree of tissue destruction. Burns are discussed in Chapter 54.

Abrupt changes in atmospheric pressure may result from high-altitude flying, deep-sea diving, and explosions. Pressure changes may interfere with gas exchange in the lungs, cause the formation of gas emboli in the bloodstream, collapse the thorax, and rupture internal organs. A well-known example of pressure injury is the condition of “the bends,” which afflicts deep-sea divers who surface too quickly. The rapid decrease in water pressure results in the formation of bubbles of nitrogen gas in the blood, which may obstruct the circulation and cause ischemic injury.

Destruction of cells and tissues resulting from mechanical deformation ranges from mild abrasion to severe lacerating trauma. Cell death may result from direct trauma to cell membranes and resulting blood loss or from obstruction of blood flow and hypoxia. Nonpenetrating trauma generally results from physical impact with a blunt object such as a fist, a car steering wheel, or the pavement. Surgery is a common cause of tissue trauma. Other causes of penetrating trauma are bite, knife, and

replicate. In some cases the virus remains in the cell for a considerable time without inflicting lethal injury. In other cases the virus causes rapid lysis and destruction of the host cell.

Virally infected cells may trigger their own destruction when they express viral proteins on the cell surface that are foreign to the host’s immune system. The hepatitis B virus is an example of such an indirectly cytopathic virus that causes immune-mediated cell death. The hepatitis B virus consists of double-stranded DNA that becomes incorporated into the host cell’s nucleus, where it can be transcribed by the normal DNA polymerases. The mRNA transcripts of the viral genes are trans- ported to the cytoplasm and translated into structural proteins and enzymes, which are used to make more copies of the virus. Some of these viral components are displayed on the cell surface where cytotoxic cells can recognize them, triggering death of the infected cells (see Chapter 9). Virally infected cells may remain functional virus factories until they are destroyed by the host’s immune system.

Chemical Injury Toxic chemicals or poisons are plentiful in the environment (Tables 4.3 and 4.4). Some toxic chemicals cause cellular injury directly, whereas others become injurious only when metabolized into reactive chemicals by the body. Carbon tetrachloride (CCl4) is an example of the latter. Carbon tetrachloride, a formerly used dry-cleaning agent, is converted to a highly toxic free radical, CCl3−, by liver cells. The free radical is highly reactive, forming abnormal chemical bonds in the cell and ultimately destroying the cellular membranes of liver cells, causing liver

TABLE 4.3 Health Effects of Outdoor Air Pollutants

Pollutant Populations at Risk Effects*

Ozone Healthy adults and children

Athletes, outdoor workers

Asthmatics

Decreased lung function Increased airway reactivity Lung inflammation Decreased exercise

capacity Increased hospitalizations

Nitrogen dioxide Healthy adults Asthmatics Children

Increased airway reactivity Decreased lung function Increased respiratory

infections Sulfur dioxide Healthy adults

Patients with chronic lung disease

Asthmatics

Increased respiratory symptoms

Increased mortality Increased hospitalization Decreased lung function

Acid aerosols Healthy adults Children Asthmatics

Altered mucociliary clearance

Increased respiratory infections

Decreased lung function Increased hospitalizations

Particulates Children Individuals with chronic

lung or heart disease Asthmatics

Increased respiratory infections

Decreased lung function Excess mortality Increased attacks

From Kumar V et al: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p 408. *See Chapters 22 and 23 for a discussion of respiratory disorders.

TABLE 4.4 Selected Indoor Air Pollutants With Significant Health Risks

Pollutant Source

Carbon monoxide Fuel combustion, fire, furnace Wood smoke Fireplaces, woodstoves Formaldehyde Manufacture of construction materials Radon Natural ground radiation Asbestos fibers Old insulation, shingles Manufactured mineral fibers Insulation, building materials Aerosols Spray bottle propellants

CHAPTER 4 Cell Injury, Aging, and Death 73

Radiation-induced cell death is attributed primarily to the radiolysis of water, with resulting free radical damage to the plasma membrane. Whole-body exposure to sufficiently high levels of radiation (300 rad) results in acute radiation sickness with hematopoietic failure, destruction of the epithelial layer of the gastrointestinal tract, and neurologic dysfunc- tion. The high levels of irradiation that cause acute radiation sickness are associated with events such as nuclear accidents and bombings. Radiation exposure from diagnostic x-rays, cosmic rays, and natural radiant chemicals in the earth is far below the level that would result in acute radiation sickness. The signs and symptoms of acute radiation sickness are shown in Fig. 4.17. The fact that radiation induces cell death in proliferating cells is used to advantage in the management of some forms of cancer. Radiation therapy may be used when a cancerous growth is confined to a particular area. Injury associated with radiation therapy is generally localized to the irradiated area. Small arteries and arterioles in the area may be damaged, leading to blood clotting and fibrous deposits that compromise tissue perfusion. Most irradiated cells are thought to die through the process of apoptosis rather than from direct killing effects of radiation. Radiation induces cell damage that triggers the apoptotic pathway in cells that cannot efficiently repair the damage. Cells most susceptible to apoptotic death are those that tend to have high rates of mitosis or meiosis.

gun wounds. Trauma-induced inflammatory swelling may further compromise injured tissues.

Electrical injury may occur when the cells of the body act as conduc- tors of electricity. The electrical current damages tissues in two ways: (1) by disruption of neural and cardiac impulses and (2) by hyperthermic destruction of tissues. Resistance to the flow of electrons results in heat production, which damages the tissues. The current tends to follow the path of least resistance—through neurons and body fluids—causing violent muscle contractions, thermal injury, and coagulation in blood vessels. In general, greater injury is suffered with high-voltage alternating current applied to a low-resistance area (e.g., wet skin).

There are many forms of electromagnetic radiation, ranging from low-energy radio waves to high-energy γ-rays or photons (Fig. 4.15). Radiation is capable of injuring cells directly by breaking chemical bonds and indirectly by generating free radicals. Cellular DNA is particularly susceptible to damage from radiation exposure. A direct hit of the radiant energy on the DNA molecule may result in breakage of the chemical bonds holding the linear DNA together. This type of direct bond breakage generally results from the high-energy forms of radiation, such as x-rays and γ-rays. The molecular bonds of DNA also may be indirectly disrupted by ionizing radiation. Ionization refers to the ability of the radiant energy to split water molecules by knocking off orbital electrons (radiolysis). Radiolysis creates activated free radicals that steal electrons from other molecules and disrupt chemical bonds. Many forms of radiation are capable of ionization, but the medium- energy α and β particles that result from decay of atomic nuclei are especially destructive. Low-energy electromagnetic radiation, such as that created by microwaves, ultrasound, computers, and infrared light, cannot break chemical bonds, but it can cause rotation and vibration of atoms and molecules. The rotational and vibrational energy is then converted to heat. It is possible that the resulting localized hyperthermia may result in cellular injury. Early studies reported a higher incidence of certain cancers in persons occupationally exposed to radiofrequency microwave electromagnetic radiation, but further analysis failed to confirm these findings.

At the cellular level, radiation has two primary effects: (1) genetic damage and (2) acute cell destruction (Fig. 4.16). The vulnerability of a tissue to radiation-induced genetic damage depends on its rate of proliferation. Genetic damage to the DNA of a long-lived, nonproliferat- ing cell may be of little consequence, whereas tissues with rapid cellular division have less opportunity to repair damaged DNA before passing it on to the next generation of cells. (Genetic mutation is discussed in Chapter 6.) Hematopoietic, mucosal, gonadal, and fetal cells are par- ticularly susceptible to genetic radiation damage.

Audio frequencies

Radio waves

Increasing frequency and increasing energy

Wavelength (meters)

Micro- waves

Infrared

X-rays

Secondary cosmic rays

V is

ib le

li g h t

U ltr

a vi

o le

t

γ-rays

1010 108 106 104 102 1 10–2 10–4 10–6 10–8 10–10 10–12 10–14

FIG 4.15 Types of electromagnetic radiation.

Acute cell destruction and

necrosis

Free radical damage to cell structures

DNA damage

Genetic mutations

Apoptosis

Ionization Direct hit on DNA

Radiant energy

FIG 4.16 The mechanism of radiation-induced genetic and cell injury.

74 UNIT II Cellular Function

is limited by the aging process itself rather than by the ravages of disease. Although the elderly are certainly more vulnerable to diseases, the aging process and disease processes are generally viewed as different phenomena. In practice, the distinction between aging and disease may be difficult to make. For example, the aging skeleton normally loses some bone mass, but too much bone loss results in osteoporosis—a disease process. Likewise, a loss of blood vessel elasticity is generally viewed as a normal aging change, but at what point does too much arterial stiffness become abnormal? This confusion results from the continued inability to identify the irreversible and universal processes of cellular aging as separate from the potentially reversible effects of disease.

Cellular Basis of Aging Cellular aging is the cumulative result of a progressive decline in the proliferative and reparative capacity of cells coupled with exposure to environmental factors that cause accumulation of cellular and molecular damage. Several mechanisms are believed to be responsible for cellular aging. These include DNA damage, reduced proliferative capacity of stem cells, and accumulation of metabolic damage.

Damage to cellular DNA is a common phenomenon resulting from various factors, including ultraviolet radiation, oxidative stress from normal metabolism, and errors in DNA replication. A host of DNA repair mechanisms is present in normal cells to prevent accumulation of DNA damage. With aging these repair systems appear to become less able to keep pace with DNA damage, and cell replication may be inhibited or apoptosis initiated. Support for this idea comes from the premature aging syndromes that are associated with defective DNA repair mechanisms.

The programmed senescence theory states that aging is the result of an intrinsic genetic program. Support for the theory of a genetically programmed life span comes primarily from studies of cells in culture. In classic experiments by Hayflick, fibroblastic cells in culture were shown to undergo a finite number of cell divisions. Fibroblasts taken from older individuals underwent fewer cell divisions than those from younger individuals. Given an adequate environment, the information encoded in the cellular genome is thought to dictate the number of possible cell replications, after which damaged or lost cells are no longer replaced. It has been postulated that cells undergo a finite number of replications because the chromosomes shorten slightly with each cell division until some critical point is reached (Fig. 4.18), at which time the cell becomes dormant or dies. The end caps of the chromosomes, called telomeres, are the sections that shorten with each cell division.

CELLULAR AGING The inevitable process of aging and death has been the subject of interest and investigation for centuries. Despite scientific study and the search for the “fountain of youth,” a satisfactory explanation for the process of cellular aging and methods for halting the aging process have not been revealed. The maximal human life span currently is about 120 years, and the oldest-known human to have lived was 122 years old. It seems apparent that aging is distinct from disease and that the life span

Cerebral edema

Bowel necrosis and ulceration,

diarrhea

Pulmonary inflammation and fibrosis

Kidney inflammation

Dermatitis

Esophagitis

Sterility

Myocarditis

Bone marrow depression with

leukopenia, anemia,

thrombocytopenia

FIG 4.17 Signs and symptoms of acute radiation sickness.

KEY POINTS • Hypoxia is an important cause of cell injury that usually results from poor

oxygenation of the blood (hypoxemia) or inadequate delivery of blood to the cells (ischemia).

• Reperfusion injury to cells may occur when circulation is restored as a result of the production of partially reduced oxygen molecules that damage cell membranes and trigger immune-mediated injury.

• Nutritional injury is a common cause of dysfunction and disease. Malnutrition is rampant in many poor countries, whereas industrialized nations are facing an epidemic of obesity-related disorders, including heart disease and diabetes.

• Cellular damage attributable to infection and immunologic responses is common. Some bacteria and viruses damage cells directly, whereas others stimulate the host’s immune system to destroy the host’s cells.

• Chemical, physical, and mechanical factors cause cell injury in various ways. Chemicals may interfere with normal metabolic processes in the cell. Injury resulting from physical factors, such as burns and frostbite, causes direct destruction of tissues. Radiation-induced cell death is primarily a result of radiolysis of water, with resulting free radical damage to the cell membrane.

Chromosome

Cell replication

Cell replication

Telomere

FIG 4.18 The end caps of the chromosomes are called telomeres. In most body cells, the telomeres progressively shorten with each cell replication until a critical point is reached, at which time the cell becomes dormant or dies.

CHAPTER 4 Cell Injury, Aging, and Death 75

Certain cells (germ cells, such as egg and sperm) are able to replenish their telomeres, which gives them potential immortality. The enzyme that rebuilds the telomeres has been named telomerase. Stem cells, which are capable of mitosis, also express telomerase, but at lower levels. Progressive loss of telomerase gene expression with aging may contribute to reduced proliferative capacity. Interestingly, a number of cancer cell types have been found to produce telomerase, whereas most differentiated somatic cells do not (Chapter 7).

Aging may also be a result of accumulated metabolic cell damage over time. The free radical theory was prompted in part by the observation that larger animals, which have slower metabolic rates, generally have longer life spans. Metabolic rate, in turn, determines the production of activated oxygen free radicals. Aging is thought to result from the cumulative and progressive damage to cell structures, particularly the cell membrane, by these oxygen radicals. Protection from metabolic damage is provided by a number of antioxidant mechanisms. Over time these protective mechanisms may become less efficient, allowing metabolic damage to accumulate in cells. Accumulated damage may eventually trigger apoptotic mechanisms leading to tissue degeneration. Altered metabolism from chronic low-calorie diets has been shown to prolong life span in studies.

Physiologic Changes of Aging All the body systems show age-related changes that can be generally described as a decrease in functional reserve or impaired ability to adapt to environmental demands. An overview of the tissue and systemic changes of aging is presented in Table 4.5. The details of age-related changes in the various body systems are described in later chapters of this book.

TABLE 4.5 Overview of the Physiologic Changes of Aging

System Physiologic Changes

Cardiovascular ↓ Vessel elasticity caused by calcification of connective tissue (↑ pulmonary vascular resistance)

↓ Number of heart muscle fibers with ↑ size of individual fibers (hypertrophy)

↓ Filling capacity ↓ Stroke volume ↓ Sensitivity of baroreceptors Degeneration of vein valves

Respiratory ↓ Chest wall compliance resulting from calcification of costal cartilage

↓ Alveolar ventilation ↓ Respiratory muscle strength Air trapping and ↓ ventilation due to degeneration of

lung tissue (↓ elasticity) Renal/urinary ↓ Glomerular filtration rate due to nephron

degeneration (↓ one third to one half by age 70) ↓ Ability to concentrate urine ↓ Ability to regulate H+ concentration

Gastrointestinal ↓ Muscular contraction ↓ Esophageal emptying ↓ Bowel motility ↓ Production of HCl, enzymes, and intrinsic factor ↓ Hepatic enzyme production and metabolic capacity Thinning of stomach mucosa

Neurologic/sensory Nerve cells degenerate and atrophy ↓ Of 25%–45% of neurons ↓ Number of neurotransmitters ↓ Rate of conduction of nerve impulses Loss of taste buds Loss of auditory hair cells and sclerosis of eardrum

Musculoskeletal ↓ Muscle mass ↑ Bone demineralization ↑ Joint degeneration, erosion, and calcification

Immune ↓ Inflammatory response ↓ In T cell function due to involution of thymus gland

Integumentary ↓ Subcutaneous fat ↓ Elastin Atrophy of sweat glands Atrophy of epidermal arterioles causing altered

temperature regulation

KEY POINTS • Aging is theoretically distinct from disease. The maximal life span is limited

by the aging process itself rather than by the ravages of disease. • Aging is thought to be the result of accumulated DNA damage, decreased

proliferative capacity of stem cells, and accumulated metabolic damage. Cells may age more quickly when DNA repair mechanisms are faulty and when metabolic damage is excessive because of reduced antioxidant activity.

• Age-related changes in body systems can generally be described as a decrease in functional reserve and a reduced ability to adapt to environmental demands.

KEY POINTS • Somatic death is characterized by the absence of respirations and heartbeat.

Definitions of brain death have been established to describe death in instances in which heartbeat and respiration are maintained mechanically.

• After death, body temperature falls, blood and body fluids collect in dependent areas, and rigor mortis ensues. Within 24 to 48 hours the tissues begin to deteriorate and rigor mortis gives way to flaccidity.

SOMATIC DEATH Death of the entire organism is called somatic death. In contrast to localized cell death, no immunologic or inflammatory response occurs in somatic death. The general features of somatic death include the absence of respiration and heartbeat. However, this definition of death is insufficient because, in some cases, breathing and cardiac activity may be restored by resuscitative efforts. Within several minutes of cardiopulmonary arrest, the characteristics of irreversible somatic death become apparent. Body temperature falls, the skin becomes pale, and blood and body fluids collect in dependent areas. Within 6 hours, the accumulation of calcium and the depletion of ATP result in perpetual actin–myosin cross-bridge formation in muscle cells. The presence of stiffened muscles throughout the body after death is called rigor mortis. Rigor mortis progresses to limpness or flaccidity as the tissues of the body begin to deteriorate. Tissue deterioration or putrefaction becomes apparent 24 to 48 hours after death. Putrefaction is associated with the widespread release of lytic enzymes in tissues throughout the body, a process called postmortem autolysis.

The determination of “brain death” has become necessary because of the technological ability to keep the heart and lungs working through

artificial means, even though the brain is no longer functional. Criteria for determining brain death as proof of somatic death may vary by geographic area but generally include unresponsiveness, flaccidity, absence of brainstem reflexes (e.g., swallowing, gagging, pupil and eye move- ments), absence of respiratory effort when the subject is removed from the mechanical ventilator, absence of electrical brain waves, and lack of cerebral blood flow.

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cell, ed 6, New York, 2015, Garland Science, pp 1021–1034. Kumar V, Abbas A, Aster J: Cellular responses to stress and toxic insults:

adaptation, injury, and death. In Kumar V, Abbas A, Aster J, editors: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, pp 31–68.

Maitra A: The endocrine system. In Kumar V, Abbas A, Aster J, editors: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, pp 1073–1140.

Nadal-Ginard B, et al: Myocyte death, growth, and regeneration in cardiac hypertrophy and failure. Circ Res 92:139–150, 2003.

Nikoletopoulou V, Markaki M, Palikaras K: Crosstalk between apoptosis, necrosis, and autophagy. Biochem Biophys Acta 2013.

Theise N, Liu C: Liver and gallbladder. In Kumar V, Abbas A, Aster J, editors: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, pp 821–882.

Van Berlo JH, Maillet M, Molkentin JD: Signaling effectors underlying pathologic growth and remodeling of the heart. J Clin Invest 123:37, 2013.

Types and Causes of Cell Injury D’Andrea JA, Ziriax JM, Adair ER: Radio frequency electromagnetic fields:

mild hyperthermia and safety standards. Prog Brain Res 162:107–135, 2007.

Guo MF, Yu JZ, Ma CG: Mechanisms related to neuron injury and death in cerebral hypoxic ischaemia. Folia Neuropathol 49(2):78–87, 2011.

Cells and tissues face many challenges to survival, including injury from lack of oxygen and nutrients, infection and immune responses, chemicals, and physical and mechanical factors. Cells respond to environmental changes or injury in three general ways: (1) If the change is mild or short lived, the cell may withstand the assault and return to its preinjury status. (2) The cell may adapt to a persistent but sublethal injury by changing its structure or function. (3) Cell death by apoptosis or necrosis may occur if the injury is too severe or prolonged. Characteristics of reversible cell injury include hydropic swelling and the accumulation of abnormal substances. Cell necrosis is characterized by irreversible loss of function, release of internal cellular components into the

bloodstream, and an inflammatory response. The disruption of the permeability barrier of the plasma membrane is a critical event in necrotic cellular death. Apoptosis is characterized by a tidy, noninflam- matory autodigestion of the cell.

Aging is a normal physiologic process characterized by a progressive decline in functional capacity and adaptive ability. The biological basis of aging remains largely a mystery, but several theories have been proposed to explain certain aspects of the process. At present, most sources differentiate between the biological alterations of aging and the alterations consequent to disease processes. In practice, however, the distinction may be difficult to make.

S U M M A R Y

77

5 Genome Structure, Regulation, and

Tissue Differentiation Jacquelyn L. Banasik

K E Y Q U E S T I O N S • How is genetic information stored in the cell and transmitted to

progeny of daughter cells during replication? • How does the simple four-base structure of DNA serve as a

template for synthesis of proteins that may contain 20 varieties of amino acids?

• What roles do genes play in determining cell structure and function?

• How is gene expression regulated? • By what mechanisms can the cells of an organism, which all

contain identical genes, become differentiated into divergent cell types?

• What are the general structures and functions of the four main tissue types: epithelial, connective, muscle, and nerve?

C H A P T E R O U T L I N E Structure and Function of DNA, 78

Structure of DNA, 78

DNA Replication, 79

Genetic Code, 80

Transcription, 81

Translation, 82

Regulation of the Genome, 84 Transcriptional Controls, 84

Differentiation of Tissues, 86 Cell Diversification and Cell Memory, 86

Mechanisms of Development, 86

Differentiated Tissues, 87

Epithelial Tissue, 87 Connective Tissue, 89 Muscle Tissue, 90 Nervous Tissue, 91

http://evolve.elsevier.com/Banasik/pathophysiology/

The ability of scientists to study and manipulate genes has evolved at an incredible pace, including the complete sequencing of all 3.2 billion nucleotide base pairs in an entire human genome. A better understanding of the role that genetics plays in cellular function and disease has spurred efforts to develop therapies to correct genetic abnormalities. The science of genetics developed from the premise that invisible, information- containing elements called genes exist in cells and are passed on to daughter cells when a cell divides. The nature of these elements was at first difficult to imagine: What kind of molecule could direct the daily activities of the organism and be capable of nearly limitless replication? The answer to this question was discovered in the late 1940s and was almost unbelievable in its simplicity. It is now common knowledge that genetic information is stored in long chains of stable molecules called deoxyribonucleic acid (DNA). The human genome contains nearly 20,000 protein-encoding genes containing only four different building blocks. These molecules are the deoxyribonucleotides containing the bases adenine (A), cytosine (C), guanine (G), and thymine (T). Genes are composed of varying sequences of these four bases, which are linked together by chains of sugar–phosphate bonds. By serving as the templates

for the production of body proteins, genes ultimately affect all aspects of an organism’s structure and function. The term genome was coined to be inclusive of the entire set of genetic and regulatory material in the nucleus and not just the genes. When the sequencing of an entire human genome was completed in 2004, it became clear that the genome is much more complex than the sum of its genes. Only 1.3% of chro- mosomal DNA codes for proteins, and many DNA sequences code for ribonucleic acid (RNA) molecules that function in the nucleus to regulate gene function. Methods to rapidly survey the DNA sequences of a particular person are available, and genetics is an increasingly important consideration in the etiology, pathogenesis, and pharmacologic treatment of a variety of diseases. However, genetic inheritance involves more than the transfer of genes from parent to offspring. For example, the nutritional exposures of grandparents may influence the metabolic physiology of grandchildren through a process known as epigenetics. Epigenetics is further explored in Chapter 6. Knowledge of the basic principles of genetics and gene regulation is a prerequisite to understand- ing not only conventional genetic diseases but also nearly every pathophysiologic process. This chapter examines the structure and

• Review Questions and Answers • Glossary (with audio pronunciations for selected terms) • Animations

• Case Studies • Key Points Review

78 UNIT II Cellular Function

function of DNA, the regulation of gene expression, and the processes of tissue differentiation. Principles of genetic inheritance precede the discussion of genetic diseases in Chapter 6.

STRUCTURE AND FUNCTION OF DNA Structure of DNA In humans, DNA encodes genetic information in 46 long, double-stranded chains of nucleotides called chromosomes. The nucleotides consist of a five-carbon sugar (deoxyribose), a phosphate group, and one of the four nucleotide bases (Fig. 5.1). The nucleotide bases are divided into two types based on their chemical structure. The pyrimidines, cytosine and thymine, have single-ring structures. The purines, guanine and adenine, have double-ring structures (Fig. 5.2). DNA polymers are formed by the chemical linkage of these nucleotides. The sugar–phosphate linkages, also called phosphodiester bonds, join the phosphate group on one sugar (attached to the five-carbon) to the three-carbon of the next sugar (see Fig. 5.1). The four kinds of bases (A, C, G, T) are attached to the repeating sugar–phosphate chain. The bases of one strand of DNA form weak bonds with the bases of another strand of DNA. These noncovalent hydrogen bonds are specific and complementary (Fig. 5.3). The bases G and C always bond together, and the bases A and T always bond together. Nucleotides that are able to bond together in this complementary way are called base pairs.

In the early 1950s, Watson and Crick proposed that the structure of DNA was a double helix. In this model, DNA can be envisioned as a twisted ladder, with the sugar–phosphate bonds as the sides of the ladder and the bases forming the rungs (see Fig. 5.3). There is one complete turn of the helix every 10 base pairs. The two strands of DNA must be complementary to form the double helix; that is, the bases of

O

O–

P

O–

P

O–

P

O O

O

O O

O

O O

H

H

PO CH2O

O–

P

CH2

A O

CH2

C O

H

Deoxyribose (sugar)

Sugar-phosphate bonds

Base

CH2

CH2

G O

HO

O O

O–

T

O

Adenine

Cytosine

Guanine

Thymine

FIG 5.1 A nucleotide consists of a sugar (deoxyribose), a phosphate group, and one of the four nucleotide bases. Nucleotides are joined by repeating sugar–phosphate bonds to form long chains, called polymers. A, Adenine; C, cytosine; G, guanine; T, thymine.

• • •

• • •

• • •

• • •

• • •

C

N C

C

N

H

N

H

H O

CH3

H

H

N

C N

C C

N

N

C

O

C

C

N C

N

H

O

N

H

O

H

H

H

N

C N

C

N

N C

C

H

N

H

H

C

H

C

Sugar- phosphate backbone

Guanine Cytosine

Adenine Thymine

Hydrogen bonds

C C

FIG 5.2 The two types of DNA bases are the single-ring pyrimidines and the double-ring purines. Thymine (T) and cytosine (C) are pyrimidines, and adenine (A) and guanine (G) are purines. Base pairing occurs between A and T and between C and G because of hydrogen bonds (dots).

CHAPTER 5 Genome Structure, Regulation, and Tissue Differentiation 79

G

A

G C

C G

A T

C

C G

C

T

T

A T

A

A

C

3' 5'

3' 5'

G

G

C G

C G

FIG 5.3 A schematic and space-filling model of the DNA double helix as proposed by Watson and Crick. The pairing of bases is specific and complementary: cytosine (C) always pairs with guanine (G), and adenine (A) always pairs with thymine (T).

one strand must pair exactly with their complementary bases on the other strand. The helix is wound around proteins called histones to form nucleosomes (Fig. 5.4). DNA coupled to histones and other nuclear proteins is termed chromatin. When a cell is not dividing, the chromatin is loosely packed within the nucleus and not visible under the light microscope. During cell division, the chromatin becomes tightly condensed into the 46 chromosomes that become visible during mitosis.

The discovery of the double-helix model was profound because it immediately suggested how information transfer could be accomplished by such simple molecules. Because each DNA strand carries a nucleotide sequence that is exactly complementary to the sequence of its partner, both strands can be used as templates to create an exact copy of the original DNA double helix. When a cell divides to form two daughter cells, each daughter cell must receive a complete copy of the parent cell’s DNA. The process of DNA replication requires separation of the DNA double helix by breaking the hydrogen bonds between the base pairs. Specific replication enzymes then direct the attachment of the correct (complementary) nucleotides to each of the single-stranded DNA templates. In this way, two identical copies of the original DNA double helix are formed and passed on to the two daughter cells during cell division.

DNA Replication Although the underlying principle of DNA replication is simple, the cellular machinery required to carry out the replication process is complex, involving a host of enzymes and proteins. These “replication machines” can duplicate DNA at a rate of 1000 nucleotides per second and complete the duplication of the entire genome in about 8 hours. The DNA double helix must first separate so that new nucleotides can be paired with the old DNA template strands. The DNA double helix is normally very stable: the base pairs are locked in place so tightly that they can withstand temperatures approaching the boiling point. In addition, DNA is wrapped around histones and bound by a host of DNA-binding proteins through which the replication machinery must navigate. DNA replication is started by special initiator proteins that pry the DNA strands apart at specific places along the chromatin, called replication origins. Then DNA helicases are needed to rapidly unwind and separate the DNA strands, whereas helix-destabilizing proteins (also called single-stranded DNA-binding proteins) bind to the exposed DNA strands to keep them apart until replication can be accomplished (Fig. 5.5). Human cells have 30,000 to 50,000 replication origins activated along the chromosomes during DNA replication to speed the process.

80 UNIT II Cellular Function

ends of the chromosomes (the telomeres), so another special enzyme complex, telomerase, is needed for this. The telomeres are fairly short, being composed of approximately 1000 repeats of a GGGTTA sequence. When the telomeres are replicated, one side of the double helix (3′ end) is always longer and loops around and tucks back into the strand. This looping structure is stabilized by a protein called shelterin that covers and protects the ends of the chromosomes. This prevents nuclear enzymes from mistaking the ends of the chromosomes for broken DNA ends and trying to attach them to each other. In many somatic cell types, telomerase activity is low and the cell’s chromosomes become slightly shorter with each cell division. Chromosomal shortening has been proposed as a mechanism of “counting” the number of replications and may be important in cellular aging and mechanisms of cancer (see Chapter 7). DNA replication is said to be semiconservative because each of the two resulting DNA double helices contains one newly synthesized strand and one original, conserved, strand (Fig. 5.6).

The DNA polymerase also has the ability to proofread the newly synthesized strands for errors in base pairing. If an error is detected, the enzyme will reverse, remove the incorrect nucleotide, and replace it with the correct one. The fidelity of copying during DNA replication is such that only about one error is made for every 10 nucleotide replica- tions. The self-correcting function of the DNA polymerases is extremely important because errors in replication will be transmitted to the next generation of cells.

Genetic Code How do an organism’s genes influence its structural and functional characteristics? A central theory in biology maintains that a gene directs the synthesis of a protein. It is the presence (or absence) and relative activity of various structural proteins and enzymes that produce the characteristics of the cell. This definition of genes as protein-coding elements is not entirely correct because many “genes” code for RNA molecules as their final functional products, and many genes code for more than one protein product through alternate splicing of the RNA messages. Protein synthesis still holds a predominant place in understand- ing how genes direct cell structure and function.

Proteins are composed of one or more chains of amino acids (polypeptides) that fold into complex three-dimensional structures. Cells contain 20 different types of amino acids that connect in a specific sequence to form a particular protein (Table 5.1). Each type of protein has a unique sequence of amino acids that dictates its structure and activity.

If genes are to direct the synthesis of proteins, the information contained in just four kinds of DNA nucleotide bases must code for 20 different amino acids. This so-called genetic code was deciphered in the early 1960s. It was determined that a series of three nucleotides (triplet) was needed to code for each of the 20 amino acids. Because there are four different bases, there are 43, or 64, different possible triplet combinations. This is far more than needed to code for the 20 known amino acids. Three of the nucleotide triplets, or codons, do not code for amino acids and are called stop codons because they signal the end of a protein code. The remaining 61 codons code for 1 of the 20 amino acids (see Table 5.1). Obviously, some of the amino acids are specified by more than one codon. For example, the amino acid arginine is determined by six different codons. The code has been highly conserved during evolution and is essentially the same in organisms as diverse as humans and bacteria.

Several intermediate molecules are involved in the process of DNA- directed protein synthesis, including the complex protein-synthesizing machinery of the ribosomes and several types of RNA. RNA is structurally similar to DNA, except that the sugar molecule is ribose rather than deoxyribose, and one of the four bases is different in that uracil replaces

As the DNA is unwound in the replication fork, it becomes overly twisted downstream, so another set of enzymes, topoisomerases, cuts nicks in the DNA and allows it to unwind to prevent tangling. Ligases repair the nicks.

Once a portion of the DNA double helix has been separated, an enzyme complex, DNA polymerase, binds the single strands of DNA and begins the process of forming a new complementary strand of DNA. DNA polymerase requires a “primer” to begin the process. Primers are formed from RNA by the enzyme DNA primase. The primase must be removed and replaced by DNA once the DNA chain is initiated. The DNA polymerases match the appropriate base to the template base and catalyze the formation of the sugar–phosphate bonds that form the backbone of the DNA strand. Replication proceeds along the DNA strand in one direction only: from the 3′ end toward the 5′ end. The ends of the DNA strands are labeled 3′ and 5′ according to the exposed carbon atom at that end. Because two complementary DNA strands are antiparallel, DNA replication is asymmetric; one strand, the leading strand, is replicated as a continuous polymer, but the lagging strand must be synthesized in short sections in a “backstitching” process (see Fig. 5.5). The backstitched fragments of DNA, called Okazaki fragments, are then sealed together by DNA ligase to form the unbroken DNA strand. DNA polymerase is unable to replicate DNA located at the very

Condensed metaphase chromosome

Supercoiled

Packed nucleosomes

“Beads-on-a- string” chromatin

Histones

DNA double helix

FIG 5.4 DNA is packaged by wrapping around protein complexes called histones to form beadlike structures called nucleosomes. During cell division, the coiled DNA becomes highly condensed into chromosomes that are visible under the light microscope. During interphase and when genes are being transcribed, the DNA is more loosely packaged and not visible.

CHAPTER 5 Genome Structure, Regulation, and Tissue Differentiation 81

and serves as the template for the synthesis of mRNA. This strand is called the sense strand. The other strand is termed the nonsense or antisense strand and is not transcribed into an RNA message. There are three types of RNA polymerases in human cells (types I, II, III), and each transcribes different categories of genes. Polymerase II transcribes protein-encoding genes and is the focus of this section.

Some genes are continuously active in certain cells, whereas others are carefully regulated in response to cellular needs and environmental

thymine. Because of the biochemical similarity of uracil and thymine, both can form base pairs with adenine. In addition, RNA forms stable single-stranded molecules, whereas DNA strands form a double-stranded molecule.

Several functionally different types of RNA are involved in protein synthesis and cell function. The number and variety of RNA molecules existing within the nucleus is large (Box 5.1), and the exact function of most has yet to be determined. Some perform messenger RNA (mRNA) splicing, ribosome assembly, and quality control of RNA messages before they are transferred to the cytoplasm. The roles of three types of RNA that participate in protein production are well understood. Ribosomal RNA (rRNA) is found associated with the ribosome (see Chapter 3) in the cell cytoplasm. Messenger RNA is synthesized from the DNA template in a process termed transcription and carries the protein code to the cytoplasm, where the proteins are manufactured. The amino acids that will be united to form proteins are carried in the cytoplasm by a third type of RNA, transfer RNA (tRNA), which interacts with mRNA and the ribosome in a process termed translation.

Transcription Transcription is the process whereby mRNA is synthesized from a single-stranded DNA template. The process is similar in some respects to DNA replication. Double-stranded DNA must be separated in the region of the gene to be copied, and specific enzyme complexes (DNA- dependent RNA polymerases) orchestrate the production of the mRNA polymer. Only one of the DNA strands contains the desired gene sequence

3'

5'

3'

Helix-destabilizing proteins

5'

Okazaki fragment

DNA primase

DNA helicase

DNA polymerase

DNA polymerase

FIG 5.5 Summary of the major proteins of the DNA replication fork. Helicase unwinds the DNA double helix, whereas helix-destabilizing proteins keep the strands from reuniting. The leading strand (top) can be replicated in a continuous manner, whereas the lagging strand (bottom) must be synthesized in pieces. Okazaki fragments are formed in a “backstitching” direction and then sealed together with DNA ligase. DNA primase synthesizes a short primer of RNA to initiate DNA polymerase activity.

mRNA—messenger RNA; codes for proteins rRNA—ribosomal RNA; within ribosomes, catalyzes protein synthesis tRNA—transfer RNA; adaptors between mRNA and amino acids in protein

synthesis snRNA—small nuclear RNA; splicing of pre-mRNA in the nucleus snoRNA—small nucleolar RNA; processing of rRNA in the nucleolus miRNA—micro RNA; regulates gene expression by blocking mRNA

translation siRNA—small interfering RNA; turns off gene expression through alteration

in chromatin piRNA—piwi-interacting RNA; protects the nucleus from transposable elements

(like prions) lncRNA—long noncoding RNA; regulates diverse processes including

X-chromosome inactivation in females

BOX 5.1 Types of RNA Produced in Cells

82 UNIT II Cellular Function

spliceosomes. The snRNAs, or small nuclear RNAs, cause the introns to loop out like a lariat, bringing the adjacent exons close together, followed by cutting and splicing. The snRNAs are combined with proteins to form molecules called small nuclear ribonucleoproteins (snRNPs) that form the core of the spliceosome. The snRNPs prevent escape through the nuclear envelope until all the necessary splicing has been accom- plished. An estimated 98% of pre-mRNA transcripts can be spliced in different ways to increase the number of different protein forms produced by a single gene.

The processed mRNA is finally transported to the cell cytoplasm through pores in the nuclear membrane that contain complexes that inspect the mRNA for certain structural characteristics that distinguish it from RNA debris. The mRNA then directs the synthesis of a protein in cooperation with tRNA and the ribosomes. Each mRNA may serve as a template for thousands of copies of protein before it is degraded.

Translation Translation is the process whereby mRNA is used to direct the synthesis of a protein. The mRNA is read in linear fashion from one end to the other, with each set of three nucleotides serving as a codon for a particular amino acid. The codons in the mRNA do not directly recognize the amino acids. Intermediary molecules, or “translators,” are required. These intermediaries are the tRNA molecules. A schematic drawing of a tRNA molecule is shown in Fig. 5.8, illustrating its L-shaped, three- dimensional structure. A codon reading area (anticodon) is located at one end and an amino acid attachment at the other. A group of specialized enzymes that have a binding pocket for a particular amino acid and a reading pocket for the anticodon are needed to attach the correct amino acid to its appropriate tRNA. The anticodon is formed by a sequence of three nucleotides. Recognition between the mRNA codon and the tRNA anticodon is accomplished by the same kind of complementary base pairing as was described for DNA. The complex machinery of the

signals. Special sequences of DNA near a desired gene may enhance or inhibit its rate of transcription. In general, a gene is transcribed when the RNA polymerase–enzyme complex binds to a promoter region just upstream of the gene’s start point. This binding event requires the cooperative function of numerous DNA-binding proteins. Once bound at the promoter, the RNA polymerase directs the separation of the DNA double helix and catalyzes the synthesis of the RNA message by matching the appropriate RNA bases to the DNA template (Fig. 5.7). The RNA message is directly complementary to the DNA sequence, except that uracil replaces thymine.

In higher organisms, the DNA template for a particular protein is littered with stretches of bases that must be removed from the original RNA transcript (pre-mRNA) before it can be translated into a protein. These intervening segments, called introns, are removed in the nucleus by a complex splicing process, resulting in an mRNA sequence that contains only the wanted segments, called exons. Introns range from 10 to 100,000 nucleotides in length. On average, 90% of a gene is composed of introns and only 10% remains in the final mRNA transcript; thus a single gene may contain dozens of introns that must be precisely removed. The function of introns remains largely a mystery, although they are believed to be important in the evolution of new genetic information and in gene regulation. Many of these intron sequences are conserved across species, which implies an important function. The presence of introns also allows alternate splicing so that one gene can be used to code for more than one protein. The removal of introns and splicing of the RNA transcript are mediated by a group of small RNA molecules located in specialized areas of the nucleus called the

Replication

Replication

Parental DNA double helix

FIG 5.6 DNA replication is semiconservative. Each of the new DNA double helices contains one newly synthesized strand and one original strand.

TABLE 5.1 RNA Codons for the Different Amino Acids and for Start and Stop

Amino Acids RNA Codons

Alanine GCU GCC GCA GCG Arginine CGU CGC CGA CGG AGA AGG Asparagine AAU AAC Aspartic acid GAU GAC Cysteine UGU UGC Glutamic acid GAA GAG Glutamine CAA CAG Glycine GGU GGC GGA GGG Histidine CAU CAC Isoleucine AUU AUC AUA Leucine CUU CUC CUA CUG UUA UUG Lysine AAA AAG Methionine AUG Phenylalanine UUU UUC Proline CCU CCC CCA CCG Serine UCU UCC UCA UCG AGC AGU Threonine ACU ACC ACA ACG Tryptophan UGG Tyrosine UAU UAC Valine GUU GUC GUA GUG Start (CI) AUG Stop (CT) UAA UAG UGA

CI, Chain initiation; CT, chain termination.

CHAPTER 5 Genome Structure, Regulation, and Tissue Differentiation 83

translating the nucleotide sequence into an amino acid sequence, one codon at a time (Fig. 5.9). The newly synthesized protein chain is released from the ribosome when a “stop codon” signaling the end of the message is reached. The new protein is typically bound by “chaperone” proteins that help it fold into its final three-dimensional shape. Amino acids belong to one of three groups—polar, nonpolar, or charged— which affects how the protein is processed and folded into its final structure (Fig. 5.10).

ribosome is needed to align the tRNA on the mRNA and to catalyze the peptide bonds that hold the amino acids together. Ribosomes are large complexes of protein and RNA. Each ribosome is composed of two subunits that are first assembled in a special part of the nucleus called the nucleolus and then transported through the nuclear pores to the cytoplasm. The smaller subunit binds the mRNA and the tRNA, whereas the larger subunit catalyzes the formation of peptide bonds between the incoming amino acids. The ribosome must first find the appropriate starting place on the mRNA to set the correct reading frame for the codon triplets. Then the ribosome moves along the mRNA,

DNA helix

RNA nucleotides RNA transcript

RNA polymerase

Unwinding site

G

A C

A T

T A

G C

A A

U

U G

C U

A

A

U

G

U

C

FIG 5.7 A moving RNA polymerase complex unwinds the DNA helix ahead of it while rewinding the DNA behind. One strand of the DNA serves as the template for the formation of mRNA.

Anticodon

3' end with

attached amino acid

FIG 5.8 Schematic drawing of a transfer RNA (tRNA) molecule. Each tRNA binds a specific amino acid, which corresponds with the three-base sequence at the anticodon end.

KEY POINTS • Genes are the basic units of inheritance and are composed of DNA located

on chromosomes. Genes direct the daily activities of the cell by controlling the production of proteins. Less than 1.5% of DNA forms genes that code for proteins. Some DNA codes for RNA transcripts that perform a variety of functions within the nucleus, but no function is known for the majority of the genomic DNA.

• The structure of DNA can be envisioned as a twisted ladder, with the sugar–phosphate bonds as the sides of the ladder and the four nucleotide bases (adenosine [A], cytosine [C], guanine [G], and thymine [T]) forming the rungs. The nucleotides form complementary base pairs: C with G and A with T.

• The DNA double helix must separate into single strands to provide a template for synthesizing new identical DNA strands that can be passed on to daughter cells during cell division. DNA replication is accomplished by the enzyme complex DNA polymerase. DNA synthesis has extremely high fidelity.

• A linear sequence of DNA that codes for a protein is called a protein-encoding gene. During transcription, genes provide a template for the synthesis of mRNA by the enzyme complex RNA polymerase.

• After a complex process of cutting and splicing of the pre-mRNA transcript within the nucleus, the mRNA is transported to the cytoplasm and translated into a protein. Each nucleotide triplet (codon) in the mRNA codes for a particular amino acid. Protein synthesis is accomplished by ribosomes, which match the mRNA codon with the correct tRNA anticodon and then catalyze the peptide bond to link amino acids together into a linear protein.

84 UNIT II Cellular Function

gene. The DNA-binding proteins are able to recognize their specific binding sites because of small variations in structure of the external surface of the DNA double helix and do not require separation of the strands to bind. These regulatory DNA-binding proteins can be catego- rized either as positive controls that activate transcription (activators) or as negative controls that inhibit transcription (repressors).

In humans, the strategies for gene regulation are complex. Gene regulatory proteins often bind DNA segments far from the gene being regulated, and binding of several gene regulatory proteins in combination is often necessary. A critical step in initiating gene transcription in human cells is the assembly of general transcription factors at the promoter region. General transcription factors are a group of DNA- binding proteins necessary for RNA polymerase activity, and initiation of transcription does not occur without them. Regulatory gene activator proteins help to collect the transcription factors at the promoter of the correct gene by first recognizing and binding to a specific DNA sequence and then coordinating the assembly of the transcription factors (Fig. 5.11).

Inhibition of transcription is achieved by gene repressor proteins, which also recognize and bind specific DNA sequences but inhibit the assembly of transcription factors at the site. Repressor proteins exert their effects through complex mechanisms, such as compacting the DNA to make it difficult to pry open, interfering with activator proteins, and binding up or inhibiting transcription factors. Inappropriate transcription of genes in a particular cell may have dire consequences for the cell or for the organism as a whole and is therefore a carefully regulated process. The presence, position, and activity of gene regulatory proteins may be regulated by various signaling cascades within the cell. Many of these signaling cascades are triggered by changes in the cell’s environment, which then alter gene transcription (see Chapter 3). This process is highly complex, with numerous signaling pathways often converging on a particular gene regulatory system. Even after the mRNA transcript is produced, it may not be allowed to reach the ribosome for translation. Small RNA molecules called micro RNA (miRNA) and small interfering RNA (siRNA) can anneal to complementary segments of the mRNA within the nucleus. In some cases, these small RNAs regulate gene splicing, but in other cases they “silence” the gene by preventing the mRNA from being translated into a protein.

REGULATION OF THE GENOME The genome contains the genetic information of the cell and ultimately determines its form and function. All the various cells in a multicellular organism contain the same genes, and differences in cell type are thought to be the result of differences in DNA expression. To maintain the cell’s phenotype, some genes must be actively transcribed, whereas others remain quiescent. In addition, the cell must be able to change the expression of certain genes to respond and adapt to changes in the cellular environment. At any one time, a cell expresses 30% to 60% of its approximately 28,000 genes (19,000 protein-coding genes and 9000 RNA genes). There is evidence that gene expression can be regulated at each of the steps in the pathway from DNA to RNA to protein synthesis. The proteins made by a cell can be controlled in the following ways: (1) regulating the rate and timing of gene transcription; (2) controlling the way the mRNA is spliced; (3) selecting the mRNAs that are trans- ported to the cytoplasm; (4) selecting the mRNAs that are translated by ribosomes; (5) selectively destroying certain mRNAs in the cytoplasm; or (6) selectively controlling the activity of the proteins after they have been produced.

For a majority of genes, the most important regulators of expression are the transcriptional controls. Approximately 10% of the cell’s protein- coding genes are devoted to making transcription-regulating proteins that are able to enhance or inhibit gene expression. These transcription regulators recognize and bind only particular DNA sequences and thus are specific to the genes they regulate. The approximately 2000 different genes that code for gene regulatory proteins work in combination to control numerous genes. The ability to regulate gene expression allows the cell to alter its structure and function in response to signals from its environment.

Transcriptional Controls The gene regulatory proteins described in the preceding paragraphs are thought to control gene transcription by binding in the major groove of the DNA double helix near the promoter sequence of the gene to be regulated. Binding of the regulatory proteins may either enhance or inhibit RNA polymerase binding and subsequent transcription of the gene. This is sometimes referred to as “turning on” or “turning off” a

Stop

Polypeptide released

Ribosome subunits released

Start

mRNA

5′ end

3′ end

Large ribosome

subunit

Small ribosome subunit

Amino acid chain

FIG 5.9 Synthesis of a protein by the ribosomes attached to an mRNA molecule. Ribosomes attach near the start codon and catalyze the formation of the peptide chain. The mRNA strand is read in groups of three nucleotides (codons) until the stop codon is reached and the peptide is released. Several ribosomes may translate a single mRNA into multiple copies of the protein.

CHAPTER 5 Genome Structure, Regulation, and Tissue Differentiation 85

CH2

CH CH3H3C

O– O+H3N C C

H

CH CH3H3C

O– O+H3N C C

H

CH3

O– O+H3N C C

H

H

O– O+H3N C C

H

CH2

SH

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H

S

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CH3

CH2

O– O+H3N C C

H

CH2

CH2 H2C

O– O+H3N C C

H

CH3

CH CH2H3C

O– O+H3N C C

H

CH2

OH

O– O+H3N C C

H

C CH3

HHO

O– O+H3N C C

H

CH2

OH

O– O+H3N C C

H

CH2

O– O+H3N C C

H

CH2

CH NH

O– O+H3N C C

H

CH2

+HN NH

O– O+H3N C C

H

C

CH2

CH2

NH2O

O– O+H3N C C

H

C CH2

NH2O

O– O+H3N C C

H

CH2

COO–

O– O+H3N C C

H

COO–

CH2

CH2

O– O+H3N C C

H

CH2

CH2

CH2

CH2

NH3 +

O– O+H3N C C

H

CH2

CH2

C NH

CH2

NH2+H2N

O– O+H3N C C

H

Tryptophan Trp W

Phenylalanine Phe F

Arginine Arg R

Lysine Lys K

Tyrosine Tyr Y

Histidine His H

Glutamine Gln Q

Glutamic acid Glu E

Aspartic acid Asp D

Asparagine Asn N

Serine Ser S

Threonine Thr T

Cysteine Cys C

Methionine Met M

Proline Pro P

Isoleucine Ile I

Leucine Leu L

Valine Val V

Alanine Ala A

Glycine Gly G

+1/2

+1+1–1–1

P O

L A

R U

N C

H A

R G

E D

U N

C H

A R

G E

D C

H A

R G

E D

FIG 5.10 The 20 amino acids that form proteins have different chemical structures that affect their solubility in lipids and water. Nonpolar amino acids tend to locate in the lipid bilayer or in the interior of globular proteins, whereas polar and charged amino acids interact well with water. (From Pollard T, Earnshaw W: Cell biology, 2007, Philadelphia, Saunders.)

86 UNIT II Cellular Function

There is substantial evidence that the differences in tissue structure and function in a particular organism are not due to deletions or additions to the genes. All the cells of an organism contain essentially the same genes. It is the expression of a relatively few tissue-specific genes that results in differences among cell types. The exact mechanisms leading to the stable expression of tissue-specific genes in particular cell types are partly unknown; however, differences in DNA packaging and the combination of gene regulatory proteins passed on during cell division are thought to be important. The DNA in human cells is extensively packaged, so that 40 inches of linear DNA can be compacted to fit into the cell nucleus. However, different regions of chromosomes can be more or less condensed (see Fig. 5.4).

Some regions of DNA, called heterochromatin, are so condensed that they are not open to transcription. It is thought that the pattern of packaging as well as the DNA-binding proteins that regulate it are transmitted to progeny when a cell divides such that the pattern of gene expression is maintained as the cell’s developmental memory. An example of this mechanism is the inactivation of one of the X chro- mosomes in females. In mammals, all female cells contain two X chromosomes (XX), whereas male cells contain an X and a Y chromosome (XY). One of the X chromosomes in females is permanently inactivated early in development by condensed packaging. This apparently occurs to prevent a double dose of the X gene products. Which of the two X chromosomes is inactivated in a particular cell is a random event. However, the same X chromosome will be inactive in all of the cell’s progeny. Methylation of cytosine nucleotides (Fig. 5.12) in specific areas of DNA with CG sequences also makes the area resistant to transcription. The pattern of methylation-inactivated genes in a particular cell type is “remembered” in subsequent generations of cells and may explain, in part, how differentiated tissues remain differentiated in the adult.

Mechanisms of Development Embryonic development is associated with selective gene expression that controls four essential processes to enable a single cell to develop into a complex organism: (1) cell proliferation, (2) cell specialization,

DIFFERENTIATION OF TISSUES Cell Diversification and Cell Memory The cells of a multicellular organism tend to specialize to perform particular functions in coordination with other cells and tissues of the body. Cells not only must become different during development, but also must remain different in the adult, after the original cues for cell diversification have disappeared. The differences among cell types are ultimately the result of the differentiating influences experienced in the embryo. Differences are maintained because the cells retain the effects of those past influences and pass the memory on to their descendants. When a skin cell divides to replace lost skin cells, the daughter cells are also skin cells; when a liver cell divides, its daughter cells are liver cells; and so on. The behavior of cells of higher organisms is governed by their genome and their present environment, as well as by their devel- opmental history.

Regulatory sequence

Gene regulatory proteins

Gene enhancer protein

TATA Gene

Mediator

Promoter

RNA polymerase

General transcription factors

Specific transcription factors (activators, repressors)

FIG 5.11 Gene activator proteins coordinate the assembly of general transcription factors at the promoter region of the gene to be transcribed. RNA polymerase is unable to bind and begin transcription until the requisite transcription factors are in place. Mediator and general transcription factors are the same for all RNA polymerase transcribed genes, but regulators are specific.

KEY POINTS • All the cells in an individual have essentially the same DNA; however, cells

differ greatly in structure and function. This occurs because genes are selectively expressed in particular cells.

• Gene expression can be regulated at any step in the pathway from DNA to RNA to protein synthesis. The most important regulators are transcriptional controls.

• A critical step for initiation of gene transcription is the assembly of general transcription factors at the promoter region of the gene.

• The actions of general transcription factors and RNA polymerase are controlled by a large number of regulatory proteins that specifically bind to DNA. The presence of certain DNA-binding proteins at specific sites can activate or repress the transcription of a particular gene in response to signals in the cell’s environment.

• A number of small RNA molecules function to regulate mRNA transcription and processing in the nucleus.

CHAPTER 5 Genome Structure, Regulation, and Tissue Differentiation 87

modulate the transport of molecules, such as growth factors, to the cell membrane and through direct contacts with the cell membrane that effect changes in cell structure and function.

The extracellular matrix surrounding the cells in different locations provides positional information to cells that must migrate to their final destination. In vertebrates, connective tissue cells appear to provide much of this positional information. While the migratory cell travels through the connective tissue, it continually samples the surroundings, searching for cues to guide it. Certain chemokines (CXCL12) and complementary receptors (CXCR4) on migratory cells are an important signaling system to help cells localize to certain areas. Migratory cells with other specific cell surface receptors may interact differentially with the extracellular matrix in different areas. In this way the migratory cell can be guided along particular paths and induced to settle in particular areas. Once the migratory cell has settled, local extracellular matrix molecules may further affect the cell’s growth rate, differentiation, and likelihood of survival.

Interactions between the extracellular matrix and nearby cells are mediated primarily by binding proteins called integrins. Integrins are transmembrane proteins that tie the cell’s cytoskeleton to particular matrix structures (see Chapter 3). They enable the cytoskeleton and extracellular matrix to communicate across the plasma membrane in specific ways. In addition to inducing cells to bind in a particular location, integrins have been shown to activate intracellular signaling pathways, which may influence cell behavior in numerous ways (e.g., cell shape, polarity, metabolism, development, and differentiation).

The steps leading to the development of differentiated tissues in a multicellular organism are such that, once differentiated, a cell type generally does not revert to earlier forms. Some cells in a tissue are terminally differentiated and have limited capacity to change form or replicate. Tissues also maintain less differentiated stem cells that are able to proliferate depending on environmental cues. Some stem cells, located mainly in the bone marrow, are quite similar to embryonic stem cells and can be recruited into tissues where they proliferate and differentiate into tissue cells. The ability of these multipotent or plu- ripotent stem cells to survive and differentiate correctly in their adopted home depends on making complex cell-to-cell and cell-to-matrix connections. In the absence of an appropriate environment, the cells will undergo apoptosis and die (see Chapter 4).

Differentiated Tissues The more than 200 different cell types in the adult human are generally classified into four major tissue categories: epithelium, connective tissue, muscle, and nerve. Tissue types and some of their subtypes are sum- marized in Table 5.2. Most of the organ systems of the body are combina- tions of these four tissue types mixed in a highly organized and cooperative manner.

Epithelial Tissue Epithelial cells cover the majority of the external surfaces of the body and line the glands, blood vessels, and internal surfaces. Epithelial cells adopt a variety of shapes and functions, depending on their locations. For example, the stratified epithelium that composes the epidermis of the skin is several layers thick and is primarily protective in function. New epithelial skin cells are formed from stem cells in the deepest part of the epidermis, where it contacts the basal lamina. As cells mature, they move outward toward the surface until they become keratinized and finally flake away (Fig. 5.13). Keratin is a tough protective protein that is present in large quantities in the outer skin layers of flattened, dead epithelial cells. The epidermis in humans is completely replaced about once per month, but turnover can occur more rapidly after injury to the skin.

(3) cell-to-cell interactions, and (4) cell movement and migration. Each time a cell divides, it must retain memory of the developmental events that have preceded the division so that it can progress along a devel- opmental pathway toward becoming a differentiated tissue. Cells have a genetic memory: the genes a cell expresses and the way it behaves depend on the cell’s past, as well as its present environment. There is no overall controlling center; each cell must make its own developmental decisions.

Two major classes of proteins are particularly important for multi- cellular development: (1) transmembrane proteins in the cell surface that participate in cell adhesion and communication and (2) DNA- binding proteins that regulate gene transcription. Differences between cells in an embryo are a necessary prelude to development of a multi- cellular organism and arise in various ways. Very early in embryonic development, cells begin to divide asymmetrically so that daughter cells are not identical—those on the outside of the group of cells receive different environmental cues than those on the inside, which are sur- rounded by other cells. These simple differences in cell-to-cell adhesion may alter the transcription of a set of genes. The altered genetic expression will then be passed on to daughter cells in the next cell division, making them diverge further from the original cell. Subsequently, the cell will respond differently to environmental influences, which further alter the cell’s structure and function. Thus cells become committed to a developmental pathway over the course of many cell divisions that transmit the history of previous exposures through sequential changes in gene expression.

Continued interactions with nearby cells, chemical gradients, and extracellular matrix components provide clues to guide the cell to its appropriate form and location in the developing organism. Chemi- cals that control the patterning of fields of nearby tissue are termed morphogens. For example, cells in the head region may specialize to secrete a “position signal” for other cells. The morphogen is progressively degraded as it diffuses through the neighboring tissue, such that it has higher concentration close to the source. A particular cell will have information regarding its proximity to the head region based on the surrounding concentration of the chemical. Morphogens are thought to be effective only over small distances. Thus the gross distinctions between head and tail, for example, must be made very early in the embryo, and morphogens can provide only a general pattern for future development. Successive levels of detail can be provided later by other positional signals.

The organization of molecules surrounding the cell surface also provides positional information. The extracellular matrix is composed of a large meshwork of molecules that is produced locally by cells in the area. Some common components include the proteins collagen and elastin; long polysaccharide chains called glycosaminoglycans; and a variety of peptides, growth factors, and hormones. The extracellular matrix is highly organized, with components binding to each other and to the cell membrane in specific ways. The extracellular matrix is thought to be important in cell development through its ability to screen or

N

N

Cytosine

Methylation

H

H

H

H

N O

N

N

H

H3C

H

H

N O

FIG 5.12 Methylation of cytosine is a common way that gene transcription is repressed.

88 UNIT II Cellular Function

TABLE 5.2 Major Categories and Location of Body Tissues

Tissue Type Locations

Epithelial Tissue Simple squamous Lining of blood vessels, pulmonary

alveoli, Bowman capsule Simple cuboidal Thyroid, sweat, and salivary glands;

kidney tubules Simple columnar Lining of intestine, glandular ducts Pseudostratified (mixed cell

shapes) Male urethra, respiratory tract passages

Stratified squamous Skin, mucous membranes Stratified columnar Epiglottis, anus, parts of pharynx Stratified transitional (layers of

different cell shapes) Bladder

Connective Tissue Loose Widespread locations, dermis of skin,

adipose tissue, organs Dense/supportive Cartilage, bone, tendons, joints, fascia

surrounding muscles Hematopoietic Bone marrow, lymph tissue, plasma

Muscle Tissue Skeletal Voluntary muscles of body Cardiac Heart (myocardium) Smooth Intestine, blood vessels, bladder, uterus,

airways Myoepithelial Mammary, sweat, and salivary glands

Nervous Tissue Neurons Central and peripheral nerves Neuroglia Primarily central nervous system

Squame flaking away from surface

Keratinized squames

Granular cell layer

Prickle cell layers

Basal cell layer

Basal lamina

D e rm

is E

p id

e rm

is

Connective tissue

FIG 5.13 Organization of epidermal skin layers, showing the flattened keratinized outer layer. Epithelial cells are continually produced by stem cells at the basal lamina and then migrate to the surface.

Simple squamous

Simple squamous

Simple columnar

Simple columnar

Pseudostratified ciliated columnar

Pseudostratified

Pseudostratified columnar Transitional

Stratified squamous

Stratified squamous

Cuboidal

Simple cuboidal

FIG 5.14 Various epithelial tissue shapes and layering.

In addition to stratified epithelium, the epithelium may be character- ized as simple or pseudostratified according to the number and arrange- ment of cell layers (Fig. 5.14). Simple epithelium consists of a single layer of cells, all of which contact the basement membrane. Simple epithelium is found in the lining of blood vessels and body cavities, in many glands, and in the alveoli of the lungs. The simple epithelium that lines the blood vessels is called endothelium. Simple epithelium also forms the kidney tubules and lines the intestine, where absorption is its primary function. Stratified epithelium consists of two or more layers of epithelial cells and is found in mucous membranes, such as the mouth, and in the skin, as mentioned previously. Epithelium that appears to be more than one layer thick because of a mixture of cell shapes but is actually a single layer is called pseudostratified epithelium. The linings of the respiratory tract and some glands contain pseudostrati- fied epithelium.

Epithelial cells may also be classified according to cell shape. The three basic cell shapes are squamous, cuboidal, and columnar. Squamous

CHAPTER 5 Genome Structure, Regulation, and Tissue Differentiation 89

in bone marrow, and the parenchymal cells (functional cells) in organs. Cell types associated with loose connective tissue include the fibroblasts, mast cells, and adipocytes (fat cells).

Dense or supportive connective tissue is rich in collagen, which gives strength to structures such as cartilage, tendon, bone, and ligaments. The collagen fibers are more organized and densely packed than fibers found in loose connective tissue. Cartilage cells, or chondrocytes, may be found in the trachea, joints, nose, ears, vertebral disks, organs, and the young skeleton. Once formed, the collagenous extracellular matrix structures require little maintenance and do not receive a blood supply. Bone is a highly dense form of connective tissue composed of a mixture of tough collagen fibers and solid calcium phosphate crystals in approximately equal proportions. Throughout the bone’s hard extracel- lular matrix are channels and cavities occupied by living cells (osteocytes) (Fig. 5.16). These cells incessantly model and remodel their bony environment, responding to environmental signals. These osteocytes are of two kinds: the cells that erode old bone are called osteoclasts, whereas the cells that form new bone are called osteoblasts. Osteoblasts detect when a bone is subjected to a greater load stress and adapt by strengthening the bone mass. Conversely, when the load is removed, as during bed rest, the osteoclasts busily digest the bone, often resulting in some of the common complications of immobility. Osteoclasts, like macrophages, are derived from monocytes that are produced in the bone marrow. The monocytes travel via the bloodstream and collect at sites of bone resorption, where they fuse together to become osteoclasts. Osteocyte activity is essential for bone growth and the repair of bone injuries. (See Chapter 50 for a detailed description of the musculoskeletal system.)

The blood-forming organs of the body contain a specialized type of connective tissue called hematopoietic tissue. The blood cells include the red cell, or erythrocyte, which is specialized for the transport of oxygen; the platelet, or thrombocyte, which is important in blood coagulation; and a host of white cells, or leukocytes, which mediate immune function. Blood-forming tissue is located in the bone marrow, spleen, and lymphatic tissue. Hematopoietic cells are necessarily nomadic, traveling to distant areas of the body and sometimes settling in a particular organ, sometimes moving continuously (Fig. 5.17). Blood cells have a short life span in comparison to other cells and must continu- ally be replenished. This is accomplished by the hematopoietic stem cells. Stem cells reside primarily in the bone marrow and are multipotent;

cells are thin in comparison to their surface area and have a flattened appearance. Cuboidal cells are approximately equal in width and height, similar to a cube. Columnar cells are a bit taller than they are wide, resembling a rectangular column. Several classifications of epithelial tissue are given in Table 5.2, using both shape and layering as criteria.

Connective Tissue Connective tissue is the most abundant and diverse tissue in the body, including cell types as different as bone cells, fat cells, and blood cells. Connective tissue commonly functions as a scaffold on which other cells cluster to form organs, but it does much more than hold tissues together. Connective tissue cells often form an elaborate extracellular matrix, which is thought to be important in the maintenance of cell differentiation. Connective tissue cells play an important part in the support and repair of nearly every tissue and organ in the body. Three major classifications of connective tissue are commonly identified: loose connective tissue, dense or supportive tissue, and hematopoietic tissue.

Loose connective tissue appears unstructured, with a fair amount of space between fibers of the extracellular matrix. The matrix contains a number of cell types and an elaborate meshwork of protein and other molecules (Fig. 5.15). The primary protein constituents are collagen, elastin, and reticular fibers. Collagen is composed of tough, nonelastic bundles of protein fibers that are secreted by fibroblasts. It gives structural strength to skin, tendons, ligaments, and other tissues. The ability of a structure to withstand deforming and stretching forces is due, in large part, to elastin, which can return to its original length after being stretched, like a rubber band. Elastin is important to the function of structures such as the aorta, which must expand to accept the blood ejected from the heart during systole and bounce back to its original shape during diastole. Reticular fibers are short branching fibers that provide networks for the attachment of connective tissue to other cell types, such as epithelial cell attachments in glands, hematopoietic cells

Collagen fibers

Fibroblast

Loose connective tissue

FIG 5.15 Scanning electron micrograph of fibroblasts in loose connective tissue of a rat cornea. The matrix is composed primarily of collagen fibers (magnification ×440). (From Solomon EP: Introduction to human anatomy and physiology, ed 4, Philadelphia, 2016, Saunders, p 38.)

Lacunae

Haversian canal

Matrix

Bone

FIG 5.16 Photomicrograph of a section of compact bone showing circular networks formed by the action of osteoclasts and osteoblasts as they remodel the bone. The osteocytes occupy the lacunae and canals. (From Solomon EP: Introduction to human anatomy and physiology, ed 4, Philadelphia, 2016, Saunders, p 38.)

90 UNIT II Cellular Function

within the cell. In skeletal muscle, the calcium originates from internal storage sites in the sarcoplasmic reticulum. Contraction is initiated when the calcium binds troponin, a regulatory protein attached to the actin filament. Because of the high energy requirements of contracting skeletal muscle, the cells are packed with energy-producing mitochondria.

Like skeletal muscle, cardiac muscle also has a striated appearance attributable to the systematic organization of its actin and myosin filaments. Cardiac muscle cells are linked by special structures, called intercalated disks and gap junctions, that cause the tissue to behave as a syncytium: all the cells contract synchronously. Cardiac muscle contracts in response to activation of pacemaker cells in the heart that have the special property of automaticity. Automaticity refers to the inherent ability of the cell to initiate an action potential without outside stimulation. The contractile mechanisms of cardiac muscle are similar to those of skeletal muscle, requiring free calcium to interact with troponin, resulting in the formation of actin–myosin cross-bridges. In cardiac muscle, some of the free calcium originates from the sarco- plasmic reticulum, but diffusion into the cell through channels in the cell membrane is also necessary. These membrane calcium channels represent an important difference from skeletal muscle, because they can be manipulated by drugs (calcium channel blockers) without disrupting skeletal muscle control. (Cardiac muscle is discussed in Chapter 17.)

Smooth muscle comprises a diverse group of tissues located in organs throughout the body. Smooth muscle generally is not under voluntary control and therefore is called involuntary muscle. Some types of smooth muscle are able to contract intrinsically, and most are influenced by the autonomic nervous system. Smooth muscle is found in blood vessels and in the walls of hollow organs, such as those of the gastrointestinal tract, uterus, and large airways.

The structure of smooth muscle differs considerably from that of skeletal and cardiac muscle, and therefore some classification schemes consider it to be a member of the connective tissue family. The actin and myosin filaments are less organized in smooth muscle, and the

they may differentiate into any of the blood cell types. This results in a system that can respond quickly to the changing needs of the body.

Muscle Tissue The term muscle refers to tissues that are specialized for contraction. Muscle cells, or myocytes, are usually long and thin and packed with the proteins actin and myosin, which constitute the contractile apparatus. In mammals, there are four main categories of muscle cells: skeletal, cardiac, smooth, and myoepithelial (Fig. 5.18). Contraction in all four types depends on the presence of intracellular free calcium and occurs because of interactions between actin and myosin filaments. Actin and myosin filaments differ among cell types with regard to amino acid sequence, arrangement within the cell, and the mechanisms that control contraction. The mechanism of muscle contraction has been called the sliding filament hypothesis or cross-bridge theory. These terms describe the interactions of the actin and myosin filaments while they form bonds and pull past each other, causing the muscle cell to shorten. Contraction is initiated by an increase in intracellular free calcium concentration and requires energy in the form of adenosine triphosphate. A detailed description of actin–myosin cross-bridging and the role of calcium, troponin, and tropomyosin can be found in Chapter 17.

Skeletal muscle is responsible for nearly all voluntary movements. Skeletal muscle cells fuse together to form long multinucleated fibers that can be huge, up to 0.5 meter (m) in length. Once fused and dif- ferentiated into mature skeletal muscle cells, they cannot enter the cell cycle and divide to produce new cells. Skeletal muscle stem cells (satellite cells) are retained in the muscle tissue and can proliferate in response to muscle damage. The actin and myosin proteins in skeletal muscle are aligned in orderly arrays, giving the tissue a striped appearance under the microscope, which in turn has led to the term striated muscle. Skeletal muscle contracts in response to stimulation from the motor neurons of the nervous system (see Chapter 50). As in other types of muscle, stimulation results in an increase in free calcium concentration

FIG 5.17 Scanning electron micrograph of red and white blood cells in the lumen of a blood vessel. Red blood cells are smooth and concave, whereas white blood cells are rough and rounded. (From Alberts B et al, editors: Molecular biology of the cell, ed 5, New York, 2008, Garland Science, p 1451. Courtesy Ray Moss.)

CHAPTER 5 Genome Structure, Regulation, and Tissue Differentiation 91

Nervous Tissue Nervous tissue is widely distributed throughout the body, providing a rapid communication network between the central nervous system and various body parts. Nerve cells are specialized to generate and transmit electrical impulses rapidly. Like muscle, nerves are excitable; they respond to stimulation by altering their electrical potentials. This excitability is caused by the presence of voltage-sensitive ion channels located in the plasma membrane of the nerve cell. Movement of ions through these channels results in the production and propagation of action potentials along the length of the neuron. Neurons communicate their action potentials to other nerve and muscle cells through synapses. At the synapse, the presynaptic neuron releases a chemical neurotransmitter into the space between itself and the next neuron (synaptic cleft), where it diffuses across and interacts with receptors on the postsynaptic neuron.

A typical neuron is composed of three parts: a cell body, an axon, and one or more dendrites (Fig. 5.20). The cell body contains the nucleus and other cytoplasmic organelles. The axon is generally long (as long as 1 m) and may be encased in a myelin sheath. The axons usually conduct impulses away from the cell body, whereas the dendritic processes usually receive information and conduct impulses toward the cell body. Neurons are classified on the basis of the number of projections extending from the cell body. Neurons are terminally differentiated and incapable of replicating. However, neural stem cells are located in certain areas of the brain like the hippocampus and may replicate to form either neurons or glial cells in response to specific signals (see Chapter 43).

muscle does not have striations. Smooth muscle contraction tends to be slower and can be maintained indefinitely. This is critical to the function of blood vessels, which must maintain a degree of contraction or vascular tone to maintain the blood pressure. Smooth muscle has no troponin and uses the protein calmodulin as the calcium-binding regulatory protein. When calmodulin binds calcium ions in the cytoplasm, it activates the enzyme myosin light chain kinase (MLCK), which phosphorylates myosin and stimulates the rate of cross-bridge formation. Actin filaments are attached to structural proteins called dense bodies that pull in the sides of the muscle cell when actin–myosin cross-bridging causes the filaments to increasingly overlap (Fig. 5.19). Smooth muscle contraction is highly dependent on the diffusion of extracellular calcium into the cell through calcium channels in the plasma membrane (sarcolemma). Thus like cardiac muscle, smooth muscle can also be affected by drugs that alter the calcium channel’s ability to conduct calcium. For example, calcium channel–blocking drugs are used to cause the smooth muscle in arterial blood vessels to relax as a treatment for high blood pressure.

Myoepithelial cells represent the fourth class of muscle cells. They are located in the ducts of some glands (e.g., mammary, sweat, and salivary). Unlike all other types of muscle, myoepithelial cells lie in the epithelium and are derived from embryonic ectoderm, whereas skeletal, cardiac, and smooth muscle are derived from embryonic mesoderm. Myoepithelial cells contract in response to specific stimuli (e.g., oxytocin in the mammary gland) and serve to expel the contents from the gland.

Skeletal muscle fibers

Nerve fibers

Bundle of smooth muscle cells

Heart muscle cells

Myoepithelial cell

Milk- secreting cell

10 �m

10 �m

10 �m

50 �m

A B

C D

FIG 5.18 The four classes of muscle cells. A, Skeletal muscle. B, Heart (cardiac) muscle. C, Smooth muscle (bladder). D, Myoepithelial cells in a mammary gland. (A and C, From Alberts B et al, editors: Molecular biology of the cell, ed 6, New York, 2015, Garland Science, p 1233. A, Courtesy Junzo Deskati. B, From Fujiwara T: Cardiac muscle. In Canal ED, editor: Handbook of microscopic anatomy, Berlin, 1986, Springer- Verlag. C, Courtesy Satoshi Nakasiro. D, From Nagato T et al: A scanning electron microscope study of myoepithelial cells in exocrine glands, Cell Tissue Res 209:1–10, 1980.)

92 UNIT II Cellular Function

Initial segment

Cell body

Nucleus

Dendrites

Axon hillock

Myelin sheath

Axon

Nodes of Ranvier

Oligodendrocyte

Axon terminal

FIG 5.20 Diagram of a typical neuron showing the cell body, axon, and dendrites. Neurons have many shapes and sizes.

Contractile filaments

Contractile filaments

Dense bodies

Dense bodies

Cytoskeleton

Cytoskeleton

A

B

Ca2+ Ca2+

FIG 5.19 Schematic drawing of a smooth muscle cell when relaxed (A) and contracted (B). Contraction begins with the entry of Ca2+ into the cell through L-type voltage-gated calcium channels. Ca2+ is also released from the sarcoplasmic reticulum. The calcium ions bind to cytoplasmic calmodulin to form a complex that activates myosin light chain kinase (MLCK). The kinase attaches a phosphate to the myosin head area, which stimulates its cycling activity. The myosin binds to actin filaments and tugs on them with each cross-bridge cycle. While the myosin and actin filaments pull closer together and overlap more, the muscle cell shortens. The actin filaments are attached to dense bodies that are analogous in function to the Z-disk protein in cardiac and skeletal muscle. Smooth muscle can maintain long-term actin–myosin cross-bridges that maintain a level of tone.

The development, differentiation, and daily activities of a cell are directed by its genome. Genes are sequences of nucleotides that provide the template for the production of RNA or cellular proteins. In large part, the kinds and amounts of cellular proteins determine cell structure and function. All the cells of the body possess essentially the same DNA,

but through complex processes of differentiation they become specialized to perform particular functions. Different sets of genes are active in different cell types. The four major classes of differentiated tissues are epithelial, connective, muscle, and nerve. These four tissues interde- pendently form the functioning systems of the body.

S U M M A R Y

In addition to neurons, nervous tissue contains a variety of supportive cells, termed neuroglia (“nerve glue”), that nourish, protect, insulate, and clean up debris in the central nervous system. These include the astrocytes, oligodendroglia, ependymal cells, and microglia. (See Chapter 43 for a detailed description of nervous system anatomy and physiology.)

KEY POINTS • The structure and function of cells are influenced by the genome and environ-

ment as well as by developmental history. • Embryonic development is associated with selective gene expression that

controls four essential processes to enable a single cell to develop into a

complex organism: (1) cell proliferation; (2) cell specialization; (3) cell-to-cell interactions; and (4) cell movement and migration.

• Many terminally differentiated cell types are unable to divide. Some tissues, such as skin and bone marrow, maintain large numbers of stem cells, which have great capacity to proliferate. Tissues are able to recruit multipotent stem cells from the bone marrow that have the capacity to become differenti- ated tissue cells if given appropriate survival and developmental conditions. Some differentiated cells, such as liver cells, maintain the ability to divide even though they are differentiated.

• Different cell types in the adult human are classified into four major categories: epithelium (e.g., skin, glands, endothelium); connective tissue (e.g., bone, cartilage, fat, blood); muscle (e.g., skeletal, cardiac, smooth); and nervous tissue (e.g., neuronal, glial).

CHAPTER 5 Genome Structure, Regulation, and Tissue Differentiation 93

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biology, Cold Spring Harbor, NY, 1966, Cold Spring Harbor Laboratory. Grunberg S, Hahn S: Structural insights into transcription initiation by RNA

Polymerase II. Trends Biochem Sci 38:603–611, 2013. Meisenberg G, Simmons WH: The human genome. In Meisenberg G,

Simmons WH, editors: Principles of medical biochemistry, ed 3, Philadelphia, 2012, Saunders, pp 93–117.

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6

Genetic and Developmental Disorders Linda D. Ward

K E Y Q U E S T I O N S • How are genes transmitted from parent to offspring? • How is pedigree analysis used to determine whether a trait is

inherited in an autosomal-dominant, autosomal-recessive, or X-linked pattern?

• How might abnormal meiosis lead to alterations in chromosome number or structure?

• What are the inheritance patterns and general clinical features of some common genetic disorders?

• What is the role of the environment in the development of congenital disorders?

• What methods of genetic testing are available?

C H A P T E R O U T L I N E Principles of Inheritance, 95

DNA Mutation and Repair, 96

GENETIC DISORDERS, 98 Chromosomal Abnormalities, 99

Aberrant Number of Chromosomes, 99

Abnormal Chromosome Structure, 100

Examples of Autosomal Chromosome Disorders, 100

Trisomy 21 (Down Syndrome), 100 Trisomy 18 (Edwards Syndrome) and Trisomy 13

(Patau Syndrome), 101 Cri du Chat Syndrome, 101

Examples of Sex Chromosome Disorders, 101 Klinefelter Syndrome, 101 Turner Syndrome, 102 Multiple X Females and Double Y Males, 102

Mendelian Single-Gene Disorders, 102 Autosomal-Dominant Disorders, 103

Marfan Syndrome, 103 Huntington Disease, 104

Autosomal-Recessive Disorders, 104 Albinism, 105

Phenylketonuria, 106 Cystic Fibrosis, 106

Sex-Linked (X-Linked) Disorders, 106 Hemophilia A, 107

Nonmendelian Single-Gene Disorders, 107 Anticipation, 109 Mitochondrial Gene Mutations, 109 Genomic Imprinting, 110

Polygenic and Multifactorial Disorders, 110 Environmentally Induced Congenital Disorders, 111

Periods of Fetal Vulnerability, 111 Teratogenic Agents, 111

Chemicals and Drugs, 111 Infectious Agents, 112 Radiation, 112

Other Disorders of Infancy, 113 Diagnosis, Counseling, and Gene Therapy, 113

Prenatal Diagnosis and Counseling, 113 Genetic Analysis and Therapy, 114 Recombinant DNA Technology, 114

http://evolve.elsevier.com/Banasik/pathophysiology/

Geneticists and parents alike have marveled at the development of a recognizable human baby, with eyes and ears, toes and fingers, from its simple beginning as a single cell containing one set of genes. Consider- ing the enormous list of potentially disastrous genetic and environmental influences, the birth of a healthy, normal child does indeed seem like a miracle. Although the risk of bearing a child with mental or physical defects is small for most parents, it is real and is often a source of worry during the prenatal period. Disorders that are present at birth are called

congenital, whether the cause is genetic, environmental, or both. Some congenital disorders are associated with structural defects attributable to errors in fetal development and are called congenital malformations. It is estimated that 2% to 3% of newborns have a major malformation of cosmetic or functional significance.

Malformations are frequently associated with genetic causes. Chro- mosomal abnormalities are thought to cause approximately 6% of congenital abnormalities, and single-gene disorders are implicated in

• Review Questions and Answers • Glossary (with audio pronunciations for selected terms) • Animations

• Case Studies • Key Points Review

CHAPTER 6 Genetic and Developmental Disorders 95

have half of the normal number of chromosomes. In contrast to mitosis (see Chapter 3), meiosis involves two divisions of chromosomal DNA. A comparison of meiotic and mitotic cell division is shown in Fig. 6.3.

During the first phase of meiosis, pairs of homologous chromosomes with duplicated sister chromatids come in close contact. Portions of the homologous chromosomes are exchanged in a process called crossing over (Fig. 6.4). This results in a mixing of the maternal and paternal genes of the cell to form a new combination of genes within the chromosomes. Genetic recombination is very precise, such that genes are exchanged intact and not interrupted in the middle. On average, each homologous pair of chromosomes has one to three crossover events occurring during the first meiotic division. The first cellular division of meiosis results in two cells, each with 46 chromosomes. These two cells undergo a second division in which the sister chromatids are pulled apart (similar to normal mitosis), resulting in four cells, each having only 23 chromosomes. Each of the germ cells has a different combination of genes that, when passed on through sexual reproduction, will form a new, genetically unique individual.

The genes that code for a particular gene product, such as an enzyme, are located at a particular position (locus) on the chromosome. Gene loci are described by their position on the long arm (q arm) or the short arm (p arm) of the chromatid. For example, the gene locus 2p13 is located on the short arm of chromosome 2 at region 1, band 3 (Fig. 6.5). Genes come in several forms, called alleles. Normally, a person has two alleles for each gene, one received from each parent. If both alleles are functionally identical, the individual is said to be homozygous for that gene. If two different alleles are present, the individual is heterozygous. Sometimes, a particular allele can cause a trait to be expressed independent of the gene’s homolog; such an allele is said to be dominant. The homologous allele whose effect is masked by a dominant allele is said to be recessive. A recessive trait is apparent only if both alleles for the trait are recessive (homozygous). It is important to remember that not all gene pairs occur in dominant and recessive forms.

Because transmission of single-gene (monogenic) traits from parent to offspring follows Mendel’s rules, inheritance can be demonstrated using a Punnett square (Fig. 6.6). In a Punnett square, alleles for a gene

7% to 8% of cases. It has been estimated that most people harbor five to eight defective genes that are recessive and therefore of little conse- quence to their health. In addition, there are many known and unknown environmental hazards to which the parent and fetus may be exposed. Environmental agents that can adversely affect the developing embryo or fetus are called teratogens and include radiation, pathogens, chemicals, and certain drugs. In half of cases, a clear explanation for a malformation cannot be found, and most congenital malformations are thought to occur due to multifactorial (genetic + environmental) causes. Some inherited genetic disorders do not become apparent until later in childhood or adulthood and therefore are not considered congenital. In this chapter, the general principles of inheritance; genetic and environmental causes of congenital disorders; and the principles of diagnosis, counseling, and gene therapy are described.

PRINCIPLES OF INHERITANCE “Whom does the baby look like?” is frequently asked of new parents. It is common knowledge that traits tend to run in families, but Gregor Mendel, a nineteenth-century monk turned geneticist, was the first to notice that certain traits in pea plants were transmitted in a predictable way from parent to offspring. The same is true for humans. Height, weight, skin color, eye color, and hair color are some of the physical traits that characterize an individual; other inherited traits contribute to risk for disease. Phenotype refers to the physical and biochemical traits or attributes of an individual that are outwardly apparent. A person’s phenotype reflects his or her unique genetic makeup, or geno- type, along with environmental factors that may affect gene expression. In some instances, a mutation in a single gene may be sufficient to cause a particular characteristic, including a disease, particularly when the gene encodes a critical protein. In the case of such single-gene (monogenic) diseases, Mendel’s principles of inheritance are useful to predict the risk of passing the disease to offspring. More often, traits (including risk for disease) are determined by multiple genes and the effects of an individual’s environment. Inheritance of these complex or multifactorial conditions is much more difficult to predict.

Human DNA is organized into 46 chromosomes which are diploid, which means they occur as 23 pairs. One member of each chromosome pair is inherited from the mother and the other from the father. Paired (homologous) chromosomes usually look identical under the microscope but differ in DNA sequence. Before cell division, chromosomes look like Xs of varying sizes and shapes. The X-shaped chromosome is really made up of two identical linear chromosome units, called chromatids, which separate during meiosis. The point at the middle of the X at which the two sister chromatids are united is the centromere (Fig. 6.1). Chromosomes are characterized on the basis of their total size, placement of the centromere, and characteristic banding patterns when exposed to certain stains (Fig. 6.2).

Of the 23 pairs of chromosomes, 22 are homologous and are called autosomes. The remaining pair consists of the sex chromosomes and differs in males and females. Females receive an X chromosome from each parent, whereas males receive an X chromosome from their mother and a Y chromosome from their father. A person’s genotype is a result of the union of 23 maternal and 23 paternal chromosomes at conception. Sexual reproduction allows the genomes of the parents to mix, producing offspring that differ genetically from one another and from their parents. This source of genetic variability is advantageous to the species because it allows for adaptation and evolution in a changing environment.

For the two germ cells (i.e., egg and sperm) to combine to form a cell with the normal complement of 46 chromosomes (23 pairs), each germ cell must contribute half of the total. Meiosis refers to a special form of cell division that results in germ cells that are haploid; they

FIG 6.1 Scanning electron micrograph of a chromosome showing the two sister chromatids attached at the centromere. Sister chromatids separate during meiosis with one chromatid being distributed to each daughter cell. (From Pollard T et al: Cell biology, ed 2, Philadelphia, 2007, Saunders, p. 224.)

96 UNIT II Cellular Function

called polygenic. Polygenic traits are heritable, but predicting their occurrence is more difficult than with single-gene traits. Polygenic traits are often affected by environmental factors (such as dietary intake, activity level, stress, and environmental exposures), which affect the ultimate expression of those genes. Such traits are said to be multifactorial; examples include height, weight, and blood pressure. Most common diseases, such as heart disease, asthma, diabetes, and cancer, are mul- tifactorial as well.

DNA Mutation and Repair The term mutation refers to a permanent change in DNA structure. Mutations can occur spontaneously, most often when copying errors occur during DNA replication, or they can be caused by exposure to mutagens such as radiation, chemicals, or viruses. Regardless of the cause, DNA changes rarely result in permanent alterations (mutations). The stability of the genes, and thus the low mutation rate, depend on efficient DNA repair mechanisms.

There are a variety of cellular DNA repair mechanisms. Most require the presence of a normal complementary DNA template to correctly repair the damaged strand of DNA. Single-stranded breaks (loss of bases from only one DNA strand) are therefore readily repaired. Double- stranded breaks, involving both strands of complementary DNA, may result in permanent loss of genetic information at the break point when

are represented by capital and lowercase letters. In the case of conditions with dominant and recessive alleles, a capital letter is used to depict the dominant allele, and a lowercase letter represents the recessive allele. Punnett squares are based on the mendelian principle that gene inheritance is random. Thus, if both parents are heterozygous for a dominant trait (Aa), the offspring will have a 25% probability of being AA, a 50% probability of being Aa, and a 25% probability of being aa. Persons having the AA and Aa genotypes may express the trait in a similar manner. If, however, the A allele is associated with a disease, being homozygous (AA) may be lethal. Achondroplasia and osteogenesis imperfecta are examples of mongenic conditions in which homozygosity for the disease allele is most often lethal. A dominant trait or condition will be absent in the aa genotype. Many genetic diseases are carried on a recessive allele and are manifested only in the homozygous (aa) genotype (e.g., cystic fibrosis, phenylketonuria [PKU]). Persons who are hetero- zygous (Aa) for conditions transmitted in a recessive pattern are said to be carriers because they are able to pass the defective recessive gene to their offspring even though they do not exhibit the trait.

Some alleles, perhaps even most alleles, are not clearly dominant or recessive and result in a blending, or codominant expression, of the trait. Blood type, for example, has three distinct alleles: A, B, and O. The A and B alleles may both be expressed, resulting in the AB blood type. Most traits result from the interaction of several genes and are

50 million DNA nucleotide pairs

1 2

3 4

5 6

7 8

9 10 11 12

13 14 15

16 17 18

19 20 21

22

x

y

FIG 6.2 A standard map of the banding pattern of each of the 23 chromosomes of the human. Somatic cells contain two copies of each chromosome. The centromere region is marked by the line. (From Alberts B et al, editors: Molecular biology of the cell, ed 6, New York, 2015, Garland Science, p. 181.)

CHAPTER 6 Genetic and Developmental Disorders 97

is normally “read” in groups of three bases, with no spaces between codons. If base pairs are added or deleted, all of the downstream codons in that gene may be changed, resulting in a protein with a greatly altered amino acid sequence (Fig. 6.8). Larger mutations may also occur and alter chromosome structure through loss, gain, or translocation of chromosome segments. These processes are discussed later in the chapter.

the broken strands are reunited. Different types of DNA damage are detected and repaired by different enzyme systems. The steps in one type of DNA repair are shown in Fig. 6.7.

Genetic mutations are generally of two types: mutations that do or do not change the “reading frame” of the gene. Recall that a sequence of three DNA bases (a codon) is required to code for each amino acid and that amino acids are connected together in a long chain to make a protein. Some mutations alter a codon so that it encodes a different amino acid; in that case, the resulting protein may not function as expected. In some cases the inclusion of the wrong amino acid in the protein is of no clinical significance; however, sickle cell anemia and beta thalassemia are examples of diseases that occur when a single-base (point) mutation causes substitution of a single amino acid. A frameshift mutation occurs when one or more bases are added or deleted and change the “reading frame” of the DNA sequence. The DNA sequence

Paternal homologous chromosome

Maternal homologous chromosome

Replication Replication

Pairing and crossover of homologous chromosomes

Chromosomes line up on the spindle

Chromosomes line up on the

spindle

Cell division

First meiotic division

Second meiotic division

MEIOSIS MITOSIS

FIG 6.3 Comparison of meiosis and normal mitotic cell division, showing only one homologous chromosome pair. In meiosis, the homologous chromosomes form a pair and exchange sections of DNA in a process called crossing over. Two nuclear divisions are required in meiosis to form the haploid germ cells.

KEY POINTS • Human DNA is organized into 46 chromosomes (23 pairs). Paired chromosomes

look similar under the microscope but differ in DNA sequence. One member of each pair is inherited from the mother and the other from the father.

• Twenty-two pairs of chromosomes are autosomes. The remaining pair, the sex chromosomes, confers maleness (XY) or femaleness (XX).

98 UNIT II Cellular Function

small percentage of those that occur and represent the less extreme aberrations that permit live birth.

Disorders that are genetic in origin traditionally have been divided into three groups: (1) chromosomal aberrations, (2) mendelian single- gene disorders, and (3) polygenic or multifactorial disorders. A fourth group encompasses a number of single-gene defects that do not follow classic mendelian patterns of inheritance. This group includes triplet

GENETIC DISORDERS Genetic disorders may be apparent at birth or may not be clinically evident until much later in life. The majority of genetic disorders are inherited from the affected individual’s parents; however, new (de novo) mutations sometimes occur during gamete formation or arise during fetal development. Genetic disorders encountered clinically are only a

Maternal chromosome

Paternal chromosome

Crossing over

Recombinant chromosomes

FIG 6.4 Crossing over during meiotic prophase I results in a reassortment of genes between homologous chromosomes.

1

2

2p13

p

Centromere

Chromosome

1

2

2

6 5

5

4

4

3

1

3

1

2

2

3 4

1 2 3 4

4 5 6 7

3

2

2

1

1

3

Long arm (q)

loci

Short arm ( )

FIG 6.5 Metaphase chromosome showing location of centromere and long and short arms of the chromatids. Gene loci are described by the chromosome number, location on short (p) or long (q) arm, region, and band.

Heterozygous parent

25% Probability

H e te

ro zy

g o u s

p a re

n t

25% Probability

A

A AA Aa

25% Probability 25% Probability

Aa aaa

a

FIG 6.6 A Punnett square shows the distribution of parental genes to their offspring. This example shows the mating of two heterozygous individuals. A, Dominant gene; a, recessive gene.

• During meiotic cell division, the chromosomes are distributed to daughter cells. Meiosis results in four daughter cells, each having half the normal number of chromosomes (23 chromosomes).

• Genes that code for a particular trait may come in several forms or alleles. Genotype refers to the particular set of alleles an individual receives. Phenotype refers to an individual’s observable attributes. People with different genotypes may have similar phenotypes.

• Some traits involve only one gene locus and are called single-gene traits. The transmission of these traits from parent to offspring follows predictable patterns. The expression of single-gene traits is determined by whether the gene is dominant or recessive. Most traits result from the interaction of several genes. These polygenic traits do not follow predictable patterns of inheritance.

CHAPTER 6 Genetic and Developmental Disorders 99

detection of much smaller structural defects, increasing the detection rate of chromosomal abnormalities.

Aberrant Number of Chromosomes The union of a human of sperm and egg results in a fertilized egg (zygote) with the full complement of 46 chromosomes: 22 pairs of autosomes and 2 sex chromosomes (euploid). Aneuploidy refers to an abnormal number of chromosomes—in humans, either more or less than 46. Aneuploidy is most commonly caused by nondisjunction. Nondisjunction means that paired homologous chromosomes fail to separate normally during one of the meiotic divisions (Fig. 6.9). The resulting germ cells then have an abnormal number of chromosomes; for example, one germ cell may have only 22 chromosomes and the other has 24 chromosomes. When one of these abnormal germ cells combines with a normal germ cell containing 23 chromosomes, the resulting zygote will either be deficient by one chromosome (45) or have an extra chromosome (47). Another cause of aneuploidy is anaphase lag, in which one chromosome lags behind and is therefore left out of

repeat (trinucleotide) mutations, mitochondrial gene mutations, and mutations influenced by genomic imprinting. General principles of transmission and selected examples are included for each of the four groups.

CHROMOSOMAL ABNORMALITIES Chromosomal defects are generally due to an abnormal number of chromosomes or alterations in the structure of one or more chromo- somes. Errors in the separation of chromosomes during meiosis may result in abnormal numbers of chromosomes. Extra or missing chro- mosomes and large structural defects (involving more than about 5 million base pairs) can be detected using traditional genetic testing methods such as karyotyping. These sorts of chromosomal abnormalities occur commonly but are usually lethal. Although they are found in at least half of spontaneous pregnancy losses (miscarriages), they have been found in only 0.5% to 1% of live-born newborn infants. In recent years, the development of molecular testing methods has allowed

Normal DNA

DNA damage

Removal of damaged base (step 1)

DNA ligase repairs nick

(step 3)

DNA polymerase inserts new base using good strand as a template

(step 2)

G

A

G C

C

C G

C

T

T

A

A

A

C G

G

G

A

C

C

C G

C

T

T

A

A

C G

G

G

A

G C

C

C G

C

T

T

A

A

C G

G

G

A

C

C

C G

C

T

T

A

A

C G

G

G

A

C

C

C G

C

T

T

A

A

C G

G

GG

A A A A

FIG 6.7 Steps of DNA repair. In step 1 the damaged section is removed; in steps 2 and 3 the original DNA sequence is restored.

A

B

NORMAL Amino acid sequence: mRNA sequence:

Lysine – Alanine – Valine – Glycine AAG GCU GUU GGC

NORMAL Amino acid sequence: mRNA sequence:

Lysine – Alanine – Valine – Glycine

Amino acid sequence: mRNA sequence: AAG GUU GGC

mRNA sequence: Amino acid sequence:

GC

AAG G CU G UU G GC

POINT MUTATION

Lysine – Threonine – Valine – Glycine ACU

FRAMESHIFT MUTATION DUE TO DELETION

Lysine – Leucine – Leucine – AA G CUG UUG

Shift Deletion Shift Shift

FIG 6.8 Schematic illustration of mutations that alter the messenger RNA sequence and the resulting protein amino acid sequence. A, Point mutation alters one amino acid. B, Frameshift mutation alters all downstream amino acids.

100 UNIT II Cellular Function

exchange of a long chromatid arm for a short one results in the formation of one very large chromosome and one very small chromosome (see Fig. 6.10). This is called a robertsonian translocation and is responsible for a rare hereditary form of Down syndrome, discussed later in the chapter. Isochromosomes occur when the sister chromatids separate incorrectly at the centromere such that the two identical short arms remain together, as do the two long arms.

Inversion refers to the removal and end-for-end reinsertion of a section of chromosome (see Fig. 6.10). Like balanced translocations, inversions involve no net loss or gain of genetic material and are often without consequence to the individual. Difficulties result, however, when homologous chromosomes attempt to pair up during meiosis. The chromosome with an inverted section may not pair up properly, resulting in duplications or loss of genes at the time of crossing over. Thus the offspring of an individual harboring an inversion may be affected.

Loss of chromosomal material is called deletion. Deletions may result when a break occurs in the arm of a single chromosome, creating a fragment of DNA with no centromere. The fragment is then lost at the next cell division. Chromosomal deletions have been associated with some forms of cancer, including retinoblastoma (see Chapter 7). Deletions at both ends of a chromatid may cause the free ends to attach to one another, forming a ring chromosome.

In contrast to a deletion, where genes are lost, duplication results in extra copies of a portion of DNA. The consequences of duplications are generally less severe than those from loss of genetic material.

Examples of Autosomal Chromosome Disorders Trisomy 21 (Down Syndrome) Trisomy 21 is a chromosomal disorder in which individuals have an extra copy of chromosome 21. It is the most common of the chromosomal disorders and a leading cause of mental disability, estimated to occur in about 1 in 700 live births. The incidence varies among populations and over time, however, and reflects trends in maternal age, prenatal diagnosis, and termination of affected pregnancies. The syndrome was

the newly formed cell nucleus. This results in one daughter cell with the normal number of chromosomes and one with a deficiency of one chromosome, a condition called monosomy. Polysomy refers to the condition of having too many chromosomes.

Aneuploidy is thought to occur rather frequently during human gametogenesis and has been associated with advanced maternal age, abnormalities in parental chromosome structure, and abnormalities in crossing over. Most often, aneuploid zygotes are nonviable. In particular, monosomy involving an autosome is not usually compatible with life. Autosomal polysomy involving a single extra copy of a chromosome carrying a small number of genes may result in a viable fetus. Severe disability, however, nearly always results (e.g., trisomy 21—Down syndrome). Disorders involving extra or missing sex chromosomes are more common and less debilitating.

Abnormal Chromosome Structure Alterations in chromosome structure are usually due to breakage and loss or rearrangement of chromosome fragments during meiosis or mitosis. During meiosis, the homologous chromosomes normally pair up and exchange genetic alleles in a process called crossing over. Normal crossing over involves precise gene exchange between homologues, with no net gain or loss of DNA. When the normal process of crossing over goes awry, portions of chromosomes may be lost, attached end-for-end, or attached to the wrong chromosome. Mitosis also presents opportunities for chromosomal breakage and rearrangement. The severity of chro- mosomal rearrangement ranges from insignificant to lethal, depending on the number and importance of the genes involved. The common types of chromosomal rearrangements are translocations, inversions, deletions, and duplications (Fig. 6.10).

Chromosomal translocations result from the exchange of pieces of DNA between nonhomologous chromosomes. If no genetic material is lost, as in a balanced or reciprocal translocation, the individual may have no symptoms or disorder. However, an individual with a balanced translocation is at increased risk of producing abnormal gametes. The

First meiotic division

Second meiotic division

Nondisjunction

Nondisjunction

FIG 6.9 Mechanism of nondisjunction leading to aneuploidy. For simplicity, only one pair of chromosomes is shown.

CHAPTER 6 Genetic and Developmental Disorders 101

Cri du Chat Syndrome Deletion of part of the short arm of chromosome 5 results in a syndrome characterized by severe mental retardation, round face, and congenital heart anomalies. The syndrome was so named because of the charac- teristic cry of the affected infant, which is caused by laryngeal malforma- tion and resembles a cat crying. Some children afflicted with this syndrome survive to adulthood, and they generally thrive better than those with the trisomies.

Examples of Sex Chromosome Disorders Klinefelter Syndrome Aneuploidies involving the sex chromosomes X or Y are much better tolerated than autosomal aneuploidies. Klinefelter syndrome occurs when a male has one or more extra copies of the X chromosome. The incidence of Klinefelter syndrome is about 1 in 600 live-born males, making it the most common sex chromosome abnormality. Most individuals with Klinefelter syndrome have a single extra copy of the X chromosome (an XXY genotype); however, individuals with more than one extra X (XXXY and XXXXY) have also been described. The presence of the Y chromosome determines the sex of these individuals to be male; however, the extra X chromosomes result in abnormal sexual development and feminization. The condition may be diagnosed at puberty, when failure to develop secondary sex characteristics may become apparent. Associated symptoms reflect low testosterone levels. Hypogonadism (small testicles) is universal in Klinefelter syndrome, most often associated with infertility. Tall stature with long arms and legs, a feminine hair distribution, gynecomastia (breast enlargement), and marginally impaired intelligence are common (Fig. 6.12). Testosterone therapy can achieve a dramatic reduction in the feminine characteristics associated with Klinefelter syndrome.

first described by Langdon Down in 1866 and is characterized by intellectual disability, protruding tongue, low-set ears, epicanthal folds, poor muscle tone, and short stature (Fig. 6.11). Children with Down syndrome often are afflicted with congenital heart deformities and an increased susceptibility to respiratory tract infections, leukemia, and early-onset Alzheimer disease. The precise causes of these signs and symptoms are poorly understood, but the increased number of genes (or gene dose) is implicated, rather than errors in DNA sequence.

In 95% of cases, the extra chromosome 21 is thought to be of maternal origin, and the incidence of trisomy 21 is clearly associated with advanced maternal age. Table 6.1 demonstrates a rise in the incidence of Down syndrome from maternal age 20 to 50 years. The reason for increased susceptibility of the ovum to nondisjunction with age remains unknown. A less common form of Down syndrome (occurring in about 4% of cases) is due to a chromosomal translocation of the long arm of chromo- some 21 to another chromosome; this is an example of a robertsonian translocation. This form of Down syndrome is not associated with increased maternal age but is passed from parent to offspring. Testing for translocations in newborns with Down syndrome is recommended to determine recurrence risk for families.

Trisomy 18 (Edwards Syndrome) and Trisomy 13 (Patau Syndrome) Trisomy of chromosome 18 or 13 occurs much less commonly than trisomy 21 and is more severe. Most affected pregnancies are lost before term, and live-born infants usually do not survive more than a few days or weeks. It is not insignificant that the few trisomy conditions compatible with life involve chromosomes containing the smallest numbers of genes. Trisomies involving chromosomes 8, 9, and 22 also have been described but are extremely rare.

TRANSLOCATIONS

ISOCHROMOSOMES

INVERSIONS

DUPLICATIONS

RING CHROMOSOMES

DELETIONS

Fragments

Fragments

Paracentric

Pericentric

Balanced reciprocal

Centric fusion

(Robertsonian) Lost

FIG 6.10 Types of chromosomal rearrangement. (Adapted from Kumar V et al: Robbins and Cotran pathologic basis of disease, ed 8, Philadelphia, 2010, Saunders, p. 160.)

102 UNIT II Cellular Function

stature, webbing of the neck, a wide chest, lymphedema of the hands and feet at birth, and failure to develop secondary sexual characteristics. Many girls with Turner syndrome also have congenital heart defects (Fig. 6.13).

Multiple X Females and Double Y Males A relatively common disorder of the sex chromosomes is the presence of an extra copy of the X chromosome in females (XXX) or of the Y chromosome in males (XYY). Most individuals appear normal and have few physical problems, although IQ may be marginally impaired.

MENDELIAN SINGLE-GENE DISORDERS In contrast to the chromosomal disorders described earlier, mendelian disorders result from mutations in single genes. The affected genes may code for enzymes, structural proteins, regulatory proteins, or regulatory RNA molecules that, due to the gene mutation, do not function as expected. An individual normally has two copies or alleles of each gene (one allele from each parent). A recessive disorder is expressed only when the individual is homozygous for the altered gene; that is, the individual has two recessive copies. Dominant disorders are expressed despite the presence or configuration of the other allele of the pair. Mendelian disorders are generally classified according to the location of the defective gene (autosomal or sex chromosome) and the mode of transmission (dominant or recessive). The great majority of mendelian disorders are familial (attributable to mutated genes inherited from the parents), but 15% to 20% represent new mutations. The occurrence of new mutations ranges widely. For example, new mutations for Hun- tington disease are rare, whereas more than 80% of individuals with achondroplasia have new mutations. A genetic pedigree may be used to trace the transmission of the disease through a family. The pedigree (Fig. 6.14) graphically displays family relationships and family members

Turner Syndrome Also known as monosomy X, Turner syndrome is associated with the presence of only one normal X chromosome and no Y chromosome. The absence of the Y chromosome results in a female phenotype; however, the ovaries fail to develop or fail prematurely. In some cases of Turner syndrome, the second X chromosome is not entirely missing but is structurally abnormal. In the majority of cases, the missing or damaged X chromosome is of paternal origin. Most fetuses with monosomy X are lost during pregnancy, and the incidence is about 1 in 2500 live female births. Principal characteristics of Turner syndrome include short

Intestinal stenosis

Predisposition to leukemia

Gap between first and

second toes

Congenital heart defects

Umbilical hernia

Mental retardation

Epicanthal folds and flat facial profile

Low-set ears

Single palmar crease

Protruding tongue

Abundant neck skin

Hypotonia

FIG 6.11 Typical clinical manifestations of trisomy 21 (Down syndrome).

TABLE 6.1 Frequency of Trisomy 21 (Down Syndrome) in Relation to Maternal Age

Age of Mother at Birth (Year)

Frequency of Trisomy 21 at Birth

20 1/1470 25 1/1333 30 1/935 35 1/353 37 1/200 39 1/112 41 1/68 43 1/46 45 1/36 50 1/26

Data from Morris JK et al: Comparison of models of maternal age-specific risk for Down syndrome live births, Prenat Diagn 23:252–258, 2003.

CHAPTER 6 Genetic and Developmental Disorders 103

disorders involve key structural proteins or regulatory proteins, such as membrane receptors. Marfan syndrome and Huntington disease are commonly cited examples of autosomal-dominant disorders and are briefly described here.

Marfan Syndrome Marfan syndrome is a disorder of the connective tissues of the body. Individuals with Marfan syndrome are typically tall and slender with long, thin arms and legs (Fig. 6.16). Because of the long, thin fingers, this syndrome has also been called arachnodactyly (“spider fingers”). It is commonly suggested that President Abraham Lincoln may have had this disorder. Although skeletal and joint deformities can be problematic, cardiovascular lesions are the most life threatening. The medial layer of blood vessels, particularly the aorta, tends to be weak and susceptible to dilation and rupture. Dysfunction of the heart valves may occur from poor connective tissue support. Marfan syndrome has been traced to hundreds of different mutations in the fibrillin 1 (FBN1) gene on chromosome 15. Fibrillin 1 is a glycoprotein that provides structural support in microfibil-rich connective tissues. Marfan syndrome

affected by diseases or conditions and is a useful tool in determining the pattern of inheritance as recessive, dominant, or sex-linked. Mendelian genetics is based on the principle that single genes are randomly and independently transmitted to offspring such that there is a 50 : 50 chance of receiving one or the other of a parent’s alleles for a particular gene. It is important to note that there are many exceptions to these rules, but they generally are useful in predicting transmission patterns for a number of single-gene disorders. Thousands of single-gene traits and disorders have been identified. A comprehensive database of the chromosomal location and sequence of these single-gene traits and disorders, called Online Mendelian Inheritance in Man, can be accessed at http://www.ncbi.nlm.nih.gov/omim.

Autosomal-Dominant Disorders Autosomal-dominant disorders occur when a mutation in a gene located on one of the autosomes is sufficient to cause the disorder despite the presence of a normal allele for the same gene. Autosomal-dominant disorders follow predictable patterns of inheritance (Fig. 6.15), which may be summarized as follows: • Males and females are equally affected. • Affected individuals usually have an affected parent. • Unaffected individuals do not transmit the disease. • Offspring of an affected individual (with an unaffected mate) have

a 1 in 2 chance of inheriting the disease. • The rare mating of two individuals, each carrying one copy of the

defective gene (heterozygous), results in a 3 in 4 chance of producing an affected offspring. For some disorders, having two copies of the defective gene is lethal. The list of known autosomal-dominant disorders is long. Many are

described in later chapters as they relate to system pathophysiology. A partial list is presented in Table 6.2. In general, autosomal-dominant

FIG 6.12 Typical clinical manifestations of Klinefelter syndrome. (From Moore KL, Persuad TVN: The developing human: clinically oriented embryology, ed 8, Philadelphia, 2007, Saunders, p. 466.)

FIG 6.13 Typical clinical manifestations of Turner syndrome. (From Connor JM, Ferguson-Smith MA: Essential medical genetics, ed 5, London, 1997, Blackwell Scientific, p. 123.)

104 UNIT II Cellular Function

acids that are coded by the CAG triplet repeat. Extra CAG repeats cause extra glutamines in the huntingtin protein, and by a mechanism that is poorly understood, the abnormally long polyglutamine repeat in the protein causes the degeneration of nerve cells in specific brain regions. Clinical manifestations and pathophysiology of Huntington disease are discussed in Chapter 45. Other disorders are also caused by expanded triple repeats; these disorders usually affect the neurologic system and are collectively called trinucleotide repeat disorders.

Autosomal-Recessive Disorders Like autosomal-dominant diseases, autosomal-recessive disorders occur due to a mutation of a gene located on one of the autosomes. Autosomal- recessive disorders, however, occur only when both alleles of a particular gene are mutated. Predictable patterns of inheritance (Fig. 6.17) are summarized as follows: • Males and females are equally affected. • In most cases, the disease is not apparent in the parents or relatives

of the affected individual, but both parents are carriers of the mutant recessive gene.

• Unaffected individuals may transmit the disease to offspring.

occurs when mutations in the fibrillin 1 gene cause abnormal fibrillin or low levels of fibrillin to be produced, leading to weakened connective tissues.

Huntington Disease Huntington disease is an autosomal-dominant disease that primarily affects neurologic function. The symptoms of mental deterioration and involuntary movements of the arms and legs do not appear until approximately age 40 years. The disease was formerly called Huntington chorea (from the Greek khoreia, meaning “dance”) because of the uncontrolled movements of the limbs. The delayed onset of symptoms means that the disease may be transmitted to offspring before the parent is aware that he or she harbors the defective gene. The prevalence rate is about 1 in 20,000 persons.

The gene abnormality in Huntington disease has been localized to chromosome 4, where an abnormally large number of triplet repeats (CAG) has been noted. Triplet repeats of more than 40 are reliably associated with development of the disease, and the greater the number of triplet repeats, the earlier the onset of symptoms. The Huntington disease protein (huntingtin) has a long segment of glutamine amino

A

B

Normal male

Affected male

Stillbirth

Marriage

Divorced

Infertility

No offspring by choice

Marriage with three children

Arrow indicates the proband

Examined personally *

Prenatal diagnosis with termination of an affected fetus

Consanguineous marriage

Normal female

Affected female

Three unaffected females

Deceased

Sex unknown

PregnantP

Identical twins

Non-identical twins

Twins of uncertain zygosity

Autosomal recessive heterozygote

Carrier female

Termination of pregnancy

Termination of affected pregnancy

3

?

FIG 6.14 A, Common symbols for pedigree analysis. B, Typical family pedigree chart.

CHAPTER 6 Genetic and Developmental Disorders 105

of two people who share the same recessive mutation parenting a child is relatively low, unless those two people are genetically related. Related individuals are much more likely to carry the same recessive genes. Because recessive diseases are only expressed when both alleles for a particular gene are mutated (homozygous), they are often associated with consanguinity—the mating of related individuals. The closer the biological relationship, the greater the proportion of shared genes and the greater the risk of producing affected offspring.

Recessive disorders often involve abnormal enzymatic function when the gene for a particular enzyme is absent or present in a mutated, nonfunctional form. Most often, enzyme deficiencies are not apparent in heterozygotes who carry one normal gene because the normal gene produces enough of the necessary enzyme. In the homozygous state, however, neither gene encoding the enzyme is functional, resulting in an enzyme deficiency. Table 6.3 includes a partial list of the large number of autosomal-recessive disorders that have been identified. Many of these diseases reflect inability to metabolize nutrients (inborn errors of metabolism) or to synthesize cellular components because of enzyme deficiencies. Albinism, PKU, and cystic fibrosis are described here as representative examples. Other disorders are described in the discussions of system pathophysiology in later chapters.

Albinism Albinism refers to a lack of pigmentation of the hair, skin, and/or eyes. There are several types of albinism; all types involve disruption of melanin synthesis. Albinism is currently classified according to the

• The mating of two carriers (heterozygous) results in a 1 in 4 chance of producing an affected offspring and a 2 in 4 chance of producing an offspring who carries the disease. It is estimated that nearly everyone carries several mutated recessive

genes, which in the homozygous state would cause disease. The odds

PUNNETT SQUARE

PEDIGREE CHART

A ff e ct

e d p

a re

n t

Affected parent

75% Probability of producing affected offspring

aaa

a

N o rm

a l p

a re

n t

Affected parent

a aa

50% Probability of producing affected offspring

aaa

a

One affected parent (Aa) One normal parent (aa)

Two affected parents (both Aa)

AA Aa

Aa

A a

Aa

A

A

A

A

B

FIG 6.15 Typical pattern of inheritance of an autosomal-dominant trait (e.g., Marfan syndrome). A, Pedigree chart. B, Punnett square.

TABLE 6.2 Autosomal-Dominant Disorders

System Disorder

Nervous Huntington disease Neurofibromatosis Myotonic dystrophy Tuberous sclerosis

Urinary Polycystic kidney disease Gastrointestinal Familial polyposis coli Hematopoietic Hereditary spherocytosis

Von Willebrand disease Skeletal Marfan syndrome

Ehlers–Danlos syndrome (some variants) Osteogenesis imperfect Achondroplasia

Metabolic Familial hypercholesterolemia Acute intermittent porphyria

From Kumar V et al: Robbins & Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p. 141.

106 UNIT II Cellular Function

Phenylketonuria PKU results from an inability to metabolize the amino acid phenylalanine because of lack of the enzyme phenylalanine hydroxylase. It is one of several enzyme deficiencies that are often referred to as inborn errors of metabolism. The symptoms of the disorder are caused by accumu- lation of dietary phenylalanine in the body, which primarily affects the nervous system. Children with PKU tend to be overly irritable and tremulous and have slowly developing mental retardation. Excess phenylalanine is excreted in the urine in the form of phenylketones, hence the name phenylketonuria. Infants typically have a musty odor because of excess phenylalanine by-products in the sweat and urine. The enzyme deficiency can be detected soon after birth and managed with a low-phenylalanine diet. Because treatment must be instituted very early to prevent mental retardation, routine screening for PKU is performed at birth.

Cystic Fibrosis Cystic fibrosis is one of the most common single-gene disorders. About 1 in 20 Caucasian Americans harbor the defective gene, and the incidence of cystic fibrosis is approximately 1 in 2500 live births. The clinical abnormalities associated with cystic fibrosis have been traced to a defect in a membrane transporter for chloride ions in epithelial cells. The alteration in chloride transport is associated with production of abnormally thick secretions in glandular tissues. The lung bronchioles and pancreatic ducts are primarily affected, often resulting in progressive destruction of these organs (see Chapter 22).

The cystic fibrosis gene was isolated in 1989 and mapped to chromo- some 7. Designated CFTR (for cystic fibrosis transmembrane conductance regulator), the gene encodes a protein chloride channel of the same name. More than 1900 different mutations of this gene have been identified, all of which cause a defect in chloride transport across the cell membrane; however, the severity of chloride channel dysfunction varies widely with different mutations. The most common mutation, accounting for about 70% of cystic fibrosis cases, involves a deletion of three nucleotides that normally code for a phenylalanine at position 508 in the CFTR protein; this mutation is designated ΔF508. The absence of this single amino acid causes the protein to fold abnormally, preventing its release from the endoplasmic reticulum, where it is eventually degraded. A schematic of the normal CFTR protein is shown in Fig. 6.18. The protein belongs to the family of ABC transporters that bind and hydrolyze adenosine triphosphate (ATP) (see Chapter 3).

The discovery and characterization of the cystic fibrosis gene and CFTR protein have made it possible to envision effective gene therapy for this disorder. Clinical trials have been published; however, overcoming host immune responses has represented a persistent barrier. Some mutation-specific drugs have been effective; for example, a novel drug, ivacaftor, was approved in 2012 for the treatment of cystic fibrosis in patients who carry a fairly rare mutation, G551D, on at least one CFTR allele. Reliable genetic screening for mutations known to cause cystic fibrosis is readily available and included as part of newborn screening in many states, making early management possible.

Sex-Linked (X-Linked) Disorders Sex-linked disorders occur because of a mutation of the sex chromosomes. Disorders linked to the Y chromosome are extremely rare, and for that reason the terms sex-linked and X-linked are often used interchangeably. Nearly all X-linked disorders are recessive, so females express the X-linked disease only in the rare instance in which both X chromosomes carry the defective gene. Males, however, do not have the safety margin of two X chromosomes and express the disease if their one and only X chromosome is abnormal. X-linked disorders follow predictable patterns

affected gene. For example, oculocutaneous albinism type 1 is associated with profound hypopigmentation of the skin and hair and reduced pigmentation of the iris and retina. Affected individuals are at risk for sunburn and skin cancer and generally exhibit impaired vision, nystagmus (involuntary eye movements), and photosensitivity.

FIG 6.16 Clinical manifestations of Marfan syndrome. Skeletal deformities such as pectus excavatum and abnormal curvature of the thoracic spine are common findings. (From Turnpenny P: Emory’s elements of medical genetics, ed 14, Philadelphia, 2012, Churchill Livingstone, p. 301.)

TABLE 6.3 Autosomal-Recessive Disorders

System Disorder

Metabolic Cystic fibrosis Phenylketonuria Galactosemia Homocystinuria Lysosomal storage disease α1-Antitrypsin deficiency Wilson disease Hemochromatosis Glycogen storage diseases

Hematopoietic Sickle cell anemia Thalassemias

Endocrine Congenital adrenal hyperplasia Skeletal Ehlers–Danlos syndrome (some variants)

Alkaptonuria Nervous Neurogenic muscular atrophies

Friedreich ataxia Spinal muscular atrophy

From Kumar V et al: Robbins & Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p. 141.

CHAPTER 6 Genetic and Developmental Disorders 107

NONMENDELIAN SINGLE-GENE DISORDERS Transmission of certain single-gene disorders may deviate from the classic mendelian principles of random and independent assortment. Three such categories have been described: (1) disorders caused by expanded triplet repeat mutations, such as fragile X syndrome; (2) disorders attributable to mitochondrial DNA mutations; and (3) disorders associated with genomic imprinting.

A

B PUNNETT SQUARE

PEDIGREE CHART

Heterozygous carrier A

A AA

25% Probability of producing affected offspring

H e te

ro zy

g o u s

ca rr

ie r

H e te

ro zy

g o u s

ca rr

ie r

Affected parent

A

50% Probability of producing affected offspring

One heterozygous carrier parent (Aa) One affected parent (aa)

Two heterozygous carrier parents (both Aa)

Aa

Aa

Aa Aa

aa a

a a

aa aa a

a

FIG 6.17 Typical pattern of inheritance of an autosomal-recessive trait (e.g., cystic fibrosis, sickle cell anemia). A, Pedigree chart. B, Punnett square.

of inheritance (Fig. 6.19), which are dependent on the sex of the offspring, and may be summarized as follows: • Affected individuals are almost always male. • Affected fathers transmit the defective gene to none of their sons

but to all of their daughters. • Unaffected males do not carry the defective gene. • A carrier female has a 1 in 2 chance of producing an affected son

and a 1 in 2 chance of producing a carrier daughter. • Females are affected only in the rare homozygous state that may

occur from the mating of an affected or carrier mother and an affected father. Several X-linked recessive disorders have been identified, as presented

in Table 6.4. A well-known example of an X-linked disease is hemophilia A.

Hemophilia A Hemophilia A is a bleeding disorder associated with a deficiency of factor VIII, a protein necessary for blood clotting. Individuals afflicted with hemophilia A bleed easily and profusely from seemingly minor injuries (see Chapter 14). The transmission of hemophilia A in the European royal families constitutes one of the best-known pedigrees available (Fig. 6.20). Queen Victoria of England was the first known carrier of the disease, and a number of her male descendants were affected.

TABLE 6.4 X-Linked Recessive Disorders

System Disorder

Musculoskeletal Duchenne muscular dystrophy Blood Hemophilias A and B

Chronic granulomatous disease Glucose-6-phosphate dehydrogenase deficiency

Immune Agammaglobulinemia Wiskott–Aldrich syndrome

Metabolic Diabetes insipidus Lesch–Nyhan syndrome

Nervous Fragile X syndrome

From Kumar V et al: Robbins & Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p. 142.

108 UNIT II Cellular Function

NORMAL

CFTR ENaC

Cl– Cl–

Cl– Cl–

Cl–

Cl– Na+Na+

Na+

Na+ Na+

Cl– Cl–

Na+

Na+

CYSTIC FIBROSIS

NORMAL CYSTIC FIBROSIS

Cl–

Cl– Cl–

Na+

Na+ Na+

LUMEN OF SWEAT DUCT

AIRWAY

H2OH2O

Normal mucus

Dehydrated mucus

FIG 6.18 Schematic illustration of the cystic fibrosis transmembrane conductance regulator (CFTR) located in an epithelial cell. CFTR is a transmembrane protein that transports chloride from the cytoplasm into the lumen of the bronchiole. Mutations in the CFTR transporter gene are believed to cause the thick secretions typical of cystic fibrosis.

x

x

x

x

x x

Father x

50% Chance of carrier daughter

50% Chance of affected son

x

y

M o th

e r

M o th

e r

Father

AFFECTED FATHER CARRIER MOTHER

x

All daughters are carriers

No sons are affected

x

y

x

x x x

x

x y

y

x y

x y

FIG 6.19 Typical inheritance pattern for X-linked disorders. The risk of disease varies according to the gender of the offspring.

CHAPTER 6 Genetic and Developmental Disorders 109

less so during spermatogenesis. Anticipation, that is, expansion of the premutation as it is passed through the female lineage, results in disease manifestation in offspring at an earlier age or with increasing severity with each succeeding generation. Because the mutation is on the X chromosome, males with fragile X syndrome tend to be more severely affected, apparently because the presence of a second X chromosome in females moderates the clinical symptoms. Other trinucleotide repeat disorders, including Huntington disease and myoclonic dystrophy, also display anticipation.

Mitochondrial Gene Mutations Nearly all genes are located in the cell nucleus; however, mitochondria in the cell cytoplasm have their own DNA (mitochondrial DNA or mtDNA), which includes several genes critical to energy production. At fertilization, mitochondria in the sperm (which are located near the tail) are lost, so mitochondrial genes are of maternal origin. Mothers transmit mitochondrial DNA to both sons and daughters, but only daughters transmit the mitochondrial genes to their offspring. Mito- chondrial DNA is much more prone to mutation than nuclear DNA. Mitochondrial DNA codes for enzymes involved in oxidative phos- phorylation and electron transport chain reactions, and mutations tend to cause dysfunction in tissues with high utilization of ATP such as nerve, muscle, kidney, and liver cells.

Anticipation Some genetic disorders deviate from typical mendelian inheritance patterns by becoming more severe and/or having earlier onset as the disorder is transmitted to future generations. This phenomenon, called anticipation, is most commonly seen in trinucleotide repeat disorders. Fragile X syndrome is a prototypical example of a trinucleotide repeat disorder that displays anticipation. Fragile X syndrome is the most common cause of familial mental retardation, exhibiting a prevalence rate of about 1 in 4000 males (1 in 8000 females). Affected individuals have an elongated (or expanded) repeat sequence composed of repeating CGG triplets in the FMR1 gene on chromosome X. The protein normally produced by FMR1 is crucial to the development and function of cerebral neurons. Normal individuals have an average of 29 CGG repeats at this gene locus. Persons with fragile X syndrome have significantly more: 200 to 2000 triplet repeats constitute a full mutation and produce the syndrome phenotype. The long repeat sequence may be visible on cytogenetic studies (karyotypes) as a characteristic narrowed segment on the long arm of the X chromosome. Persons who have an intermediate number of repeats (60 to 200) are said to have a premutation. Although they themselves do not have features of fragile X syndrome, they are at significant risk for producing affected offspring. The premutation is unstable and predisposed to expansion during oogenesis, but much

British royal house

Spanish royal house

Prussian royal house

German royal house

Russian royal house

George III

Frederick III

Alice Duke of Hesse

Alfred Helena Arthur Leopold Beatrice Prince Henry

No hemophilia No hemophilia

Duke of Windsor

Lady Diana

Prince Charles

William Henry

Anne Andrew

Edward

Queen Elizabeth II

Prince Philip

Margaret

King George VI

Earl of Mountbatten

Prince Sigismond

Henry Anastasia Alexis Viscount Trematon

Alfonso Jamie

No evidence of hemophilia

King Juan Carlos

No evidence of hemophilia

Juan Gonzalo

Alfonso King of Spain

Queen Eugenie

LeopoldMaurice Princess

Alice

Earl of Athlone

Czarina Alexandra

Czar Nicholas II

Irene

?

??

?

? ?? Waldemar

Edward Duke of Kent

Louis II Grand Duke of Hesse

Queen Victoria

King Edward VII

King George V

Victoria

Prince Albert

FIG 6.20 Pedigree chart for the transmission of the X-linked disease hemophilia A in the royal families of Europe.

110 UNIT II Cellular Function

syndrome arises according to whether the deletion is on the maternal or paternal chromosome (Fig. 6.21). These findings imply that the cell is not blind to the parental origin of chromosomes and that homologous chromosomes may be marked and function differently within the cell.

POLYGENIC AND MULTIFACTORIAL DISORDERS Most human traits develop in response to more than one gene; such traits are called polygenic. Environmental influence also has a role in gene expression; traits and disorders influenced by multiple genes as well as environmental factors are called multifactorial. Examples of multifactorial traits are height, weight, and intelligence. Most common health conditions and disorders, including obesity, hypertension, diabetes and depression, are also multifactorial. Multifactorial traits do not follow clear-cut modes of inheritance but do tend to “run in families.” Char- acteristics determined by multifactorial inheritance tend to have a range of expression in the population and demonstrate a “bell curve” distribu- tion. They are thought to be produced by the interaction of several genes, each contributing a small additive effect and modulated by environmental influences, such as diet, activity, stress, and environmental exposures. Most multifactorial disorders present a range of severity, although a few disorders are either present or absent. In the latter case, it may be that a certain threshold number of defective genes must be inherited before the disease is expressed.

It is extremely difficult to predict the risk of occurrence of multifacto- rial disorders based on family history. Based on observing inheritance in the population, however, empirical estimates have been derived. Recurrence risk is specific for each disorder and varies among different populations, but in general the risk is much less than that found in mendelian disorders. As an example, neural tube defects, which are

Genomic Imprinting The concept of genomic imprinting challenges the long-held belief that the parental origin of a gene does not make any difference to the cells that inherit the gene. Genomic imprinting is a process whereby maternal and paternal genes are marked differentially by chemical tags that alter gene expression, such as silencing the gene. This chemical marking of genes is an example of an epigenetic effect, which is an alteration to DNA that does not involve a change in the sequence of a gene. Epigenetic effects, which are thought to play a critical role in gene expression, are both heritable and reversible.

Genomic imprinting can be illustrated by considering two very different syndromes, which at first glance appeared to be a result of the same chromosomal defect. Prader–Willi syndrome and Angelman syndrome both result from a fairly large deletion at the same location on chromosome 15 that includes several genes. Prader–Willi syndrome is characterized by mental retardation, short stature, obesity, poor muscle tone, and hypogonadism. Patients with Angelman syndrome are also mentally retarded, but they have ataxia and seizures and tend to laugh inappropriately. The fact that two different syndromes result from the same mutation was puzzling until it was discovered that Prader–Willi is associated with a deletion on the paternally derived chromosome 15, whereas the Angelman syndrome is associated the same deletion on the maternally derived chromosome 15. Both the “Angelman gene” and the “Prader–Willi gene” are normally present in the region of the deletion. The “Angelman gene” is normally active on a maternal chromosome and silent (due to imprinting) on the paternal chromosome, whereas the “Prader–Willi gene” is normally active on only the paternal chromosome and silent on the maternal chromosome. Thus normal cells have only one functional copy of each gene. The disorders arise when there is a deletion of chromosome 15 involving those genes, and a different

Imprinted Prader-Willi gene Active Angelman gene

Imprinted Prader-Willi gene Active Angelman gene

Active Prader-Willi gene Imprinted Angelman gene

Active Prader-Willi gene Imprinted Angelman gene

MATERNAL (M)

PATERNAL (P)

(M) (P) (M) (P)

Deletion in maternal

chromosome

Deletion in paternal

chromosome

Site of deletion

ANGELMAN SYNDROME PRADER-WILLI SYNDROME

Site of deletion

FIG 6.21 Angelman and Prader–Willi syndromes are examples of genetic imprinting, where the location of a mutation on the maternal or paternal homologous chromosome produces a different outcome.

CHAPTER 6 Genetic and Developmental Disorders 111

multifactorial, occur in 2% to 3% of siblings of affected individuals. Based on such a recurrence risk, parents of one affected child have a 2% to 3% chance of bearing a second affected child.

In contrast to single-gene and chromosomal abnormalities, which are rare, multifactorial disorders are very common. High blood pressure, atherosclerosis, cancer, diabetes mellitus, cleft lip, and several forms of congenital heart defects are transmitted by multifactorial inheritance. This list is destined to grow as knowledge of the role of genetic mecha- nisms in cellular function and disease expands.

TABLE 6.5 Causes of Congenital Malformations in Humans

Cause Malformed Live Births (%)

Genetic Chromosomal aberrations 10–15 Mendelian inheritance 2–10

Environmental Maternal/placental infections (e.g., rubella,

toxoplasmosis, syphilis, cytomegalovirus, human immunodeficiency virus)

2–3

Maternal disease states (e.g., diabetes, phenylketonuria, endocrinopathies)

6–8

Drugs and chemicals (e.g., alcohol, androgens, folic acid antagonists, phenytoin, thalidomide, warfarin, 13-cis-retinoic acid)

≈1

Irradiation ≈1

Multifactorial 20–25

Unknown 40–60

Adapted from Stevenson RE et al, editors: Human malformations and related anomalies, New York, 1993, Oxford University Press, p. 115; Kumar V et al: Robbins & Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p. 454.

KEY POINTS • Genetic disorders are of three general types: chromosomal aberrations,

single-gene disorders, and polygenic/multifactorial disorders. • Chromosome disorders result from an abnormality in number or structure.

The presence of only one chromosome of a homologous pair is termed monosomy (e.g., Turner syndrome), and the presence of an excessive number of chromosomes is called polysomy (e.g., Down syndrome). Abnormal rearrangement of portions of the chromosomes (translocation, inversion, deletion, duplication) can result in loss or unusual expression of genes.

• Single-gene disorders result from mutations that alter the nucleotide sequence of one particular gene. Mendelian disorders are transmitted predictably in autosomal-dominant (e.g., Huntington disease), autosomal-recessive (e.g., cystic fibrosis), and sex-linked (e.g., hemophilia) patterns.

• Some single-gene disorders have unusual transmission patterns, which violate Mendel’s laws. These include expanded triplet repeat mutations, mitochondrial DNA mutations, and genomic imprinting disorders.

• Multifactorial disorders are very common and result from the interaction of multiple genes and environmental influences. Disorders such as high blood pressure, cancer, and diabetes are multifactorial.

ENVIRONMENTALLY INDUCED CONGENITAL DISORDERS Adverse influences during intrauterine life are a significant cause of errors in fetal development that result in congenital malformations. The study of abnormal physical development (morphogenesis) is called dysmorphology. Most malformations are associated with genetic causes; however, exposure to certain environmental agents, such as chemicals, radiation, maternal disease states, and viruses, may adversely affect the developing fetus (Table 6.5). Agents that cause congenital malformation are called teratogens. Many substances, including some medications, are thought to have teratogenic potential, based on experiments in animals, but few are proved in humans. Exposure to a known teratogen may, but need not, result in a congenital malformation. Susceptibility to a teratogen depends on the amount of exposure, the developmental stage of the fetus when exposed, the prior condition of the mother, and the genetic predisposition of the fetus.

Periods of Fetal Vulnerability The timing of the exposure to a teratogen greatly influences fetal susceptibility and the resulting type of malformation. The intrauterine development of humans can be divided into two stages: (1) the embryonic period, which extends from conception to 9 weeks of development, and (2) the fetal period, which continues until birth. Before the third week of gestation, exposure to a teratogen generally either damages so few cells that the embryo develops normally, or damages so many cells that the embryo cannot survive and spontaneous abortion occurs. Between the third and ninth weeks of gestation the embryo is very vulnerable to teratogenesis, with the fourth and fifth weeks being the

time of peak susceptibility. Organ development (organogenesis) occurs during this period, and this complex process is very sensitive to injury, regardless of the cause. Each organ has a critical period during which it is most vulnerable to malformation (Fig. 6.22). Unfortunately, an embryo may be exposed to teratogens during the vulnerable period because the mother does not yet realize she is pregnant. During the fetal period, from 3 to 9 months, organs undergo further growth and maturation, and susceptibility to errors of development is significantly less. Fetal insults occurring after the third month are more likely to result in growth retardation or injury to normally formed organs.

Teratogenic Agents The teratogenic potential of many agents is unknown. Several chemicals, some infections, and large doses of radiation are definitely associated with a higher risk of congenital disorders. In general, teratogens cause errors in morphogenesis by interfering with cell proliferation, migration, or differentiation. The specific mechanisms of action of most teratogens are unknown.

Chemicals and Drugs The list of proven teratogenic chemicals and drugs includes thalidomide, alcohol, anticonvulsants, warfarin, folate antagonists, androgenic hormones, angiotensin-converting enzyme inhibitors, and organic mercury. Almost no drugs or chemicals are considered totally safe, and the current trend is to discourage pregnant women from using any drugs or chemicals. A classification system for determining relative risk of medications in pregnancy has been developed (Table 6.6). Two agents, thalidomide and alcohol, illustrate the teratogenic potential of chemicals.

In the 1960s, an increase in the incidence of congenital limb deformi- ties was traced to maternal use of thalidomide, a tranquilizer, during

112 UNIT II Cellular Function

the time of infection is critically important. Perhaps the best known viral teratogen is rubella. The risk period for rubella infection begins just before conception and extends to 20 weeks’ gestation, after which the virus rarely crosses the placenta. Rubella-induced defects vary but typically include cataracts, deafness, and heart defects. Several other organisms cause a similar constellation of congenital defects; therefore the acronym TORCH was developed to alert clinicians to the potential teratogenicity of these infections. TORCH stands for toxoplasmosis, others, rubella, cytomegalovirus, herpes. The major features of the TORCH complex are shown in Fig. 6.23. The category of “others” includes several less frequently seen causes: hepatitis B, coxsackievirus B, mumps, poliovirus, zika virus, and others. All microorganisms of the TORCH complex are able to cross the placenta and infect the fetus.

Toxoplasmosis is a protozoal infection that can be contracted from ingestion of raw or undercooked meat and from contact with cat feces. Cytomegalovirus and herpes simplex virus are generally transmitted to the fetus by chronic carrier mothers. Cytomegalovirus and herpes simplex virus often colonize in the genital area of the mother. Infants who escape infection in utero may still acquire the virus as they pass through the birth canal (see Chapter 34).

Radiation In addition to being mutagenic, radiation is teratogenic. The teratogenic potential of radiation became apparent from the increased incidence of congenital malformations in children born to women who underwent irradiation of the cervix for cancer and in the children of atomic bomb victims in World War II. It is not known if lower levels of radiation, such as those used in diagnostic x-rays, are teratogenic. It is generally

early pregnancy. Exposure during the vulnerable period (20 to 35 days after conception) was associated with a very high risk of fetal malforma- tion. Typically, the arms were short and flipperlike, although deformities ranged from mild abnormalities of the digits to complete absence of the limbs. Damage to other structures, particularly the ears and heart, also occurred. Thalidomide is one of the most potent teratogens known.

Prenatal exposure to alcohol is known to be associated with a wide spectrum of congenital conditions referred to as fetal alcohol spectrum disorder (FASD). Fetal alcohol syndrome (FAS) represents the severe end of the spectrum. It is estimated that between 0.2 and 1.5 of every 1000 newborns suffer from FAS. The prevalence of FASD is estimated to be much higher, reaching 1% and much higher in populations with high alcohol use among women of childbearing age. Affected infants display characteristic facial abnormalities and suffer from growth retardation, developmental delay, and learning and behavioral problems, with alterations to the developing brain resulting in the most devastating deficits. Multiple mechanisms for alcohol teratogenesis have been suggested. Data are insufficient to determine what, if any, level of alcohol intake during pregnancy is safe. It is clear that factors other than the absolute amount of alcohol intake during pregnancy are important in determining risk of FAS. Complete abstinence from alcohol during pregnancy is recommended.

Infectious Agents A number of perinatal infections have been implicated in the development of congenital malformations. Certain viral infections appear to carry the greatest threat, although protozoa and bacteria have also been implicated. As with other teratogens, the gestational age of the fetus at

Major morphologic abnormalities Prenatal death

Central nervous system

Heart

Arms

Eyes

Legs

Teeth

Palate

Ears

External genitalia

1 2 3 4 5 6 7 8 9

C o n ce

p tio

n

Physiologic defects and minor morphologic defects

Embryonic period (weeks)

FIG 6.22 Vulnerable periods of fetal organ development.

CHAPTER 6 Genetic and Developmental Disorders 113

DIAGNOSIS, COUNSELING, AND GENE THERAPY In recent years, the ability to diagnose and manage genetic and devel- opmental disorders has improved dramatically. Although pedigree analysis continues to be an important method for identifying at-risk individuals, for a number of disorders it is now possible to determine whether parents carry defective genes or if a particular fetus is afflicted. Currently, the ability to detect genetic mutations far exceeds the ability to offer definitive genetic treatment, triggering many ethical concerns. Unfortunately, many individuals at risk for transmitting recessive genetic diseases are not identified until the birth of an affected child. Genetic counseling and prenatal assessment then become extremely important in assisting the family in regard to future pregnancies.

Prenatal Diagnosis and Counseling A number of conditions are associated with a higher risk of congenital anomalies and are indications for instituting counseling and prenatal diagnostic examination. These conditions include (1) a maternal age of 35 years or greater; (2) a history of previously bearing a child with a chromosomal disorder (such as trisomy 21); (3) a known family history of X-linked disorders; (4) a family history of inborn errors of metabolism; (5) the occurrence of neural tube anomalies in a previous pregnancy; and (6) awareness that the mother is a known carrier of a recessive genetic disorder. As diagnostic methods become more cost effective, general screening for other risk factors may be undertaken. Screening for genetic disorders may utilize ultrasound or maternal blood, but prenatal diagnostic testing usually requires invasive procedures such as amniocentesis, chorionic villus biopsy, or (rarely) umbilical cord blood sampling. Postnatal genetic analysis is usually done on peripheral blood samples of lymphocytes.

recommended that pregnant women avoid diagnostic x-rays or be provided appropriate lead shielding if x-rays are required.

Other Disorders of Infancy An infant may be afflicted with a variety of problems at birth that do not fall into the category of genetic or developmental malformations. These problems generally arise later in uterine life and often involve mechanical factors or problems with the health of the mother and placenta. For example, babies with low birth weight or immaturity at birth may have difficulty breathing and taking in adequate nutrition. Interruption of the placental oxygen supply because of maternal hemor- rhage, sedation, or blood incompatibility may result in fetal brain injury. A difficult labor and delivery may result in a variety of injuries during the birth process. The details of these disorders of infancy and childhood may be found in specialized texts.

TABLE 6.6 Pregnancy Categories for Medication Administration

Category Interpretation

A Adequate and well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities to the fetus in any trimester of pregnancy.

B Animal studies have revealed no evidence of harm to the fetus; however, there are no adequate and well- controlled studies in pregnant women.

OR Animal studies have shown an adverse effect, but

adequate and well-controlled studies in pregnant women have failed to demonstrate risk to the fetus in any trimester.

C Animal studies have shown an adverse effect, and there are no adequate and well-controlled studies in pregnant women.

OR No animal studies have been conducted, and there are no

adequate and well-controlled studies in pregnant women.

D Adequate and well-controlled or observational studies in pregnant women have demonstrated risk to fetus. However, benefits of therapy may outweigh potential risk. For example, the drug may be acceptable if needed in a life-threatening situation or serious disease for which safer drugs cannot be used or are ineffective.

X Adequate and well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities or risks.

Use of the product is contraindicated in women who are or may become pregnant.

Heart defects

Hepatomegaly and jaundice

Splenomegaly

Pneumonitis

Microcephaly

Small eyes

Petechiae and purpura

FIG 6.23 Major clinical findings in the TORCH (toxoplasmosis, others, rubella, cytomegalovirus, herpes) complex of infective congenital disorders.

KEY POINTS • Environmental factors that adversely affect the developing fetus are called

teratogens. Exposure to teratogens is particularly dangerous during the third to ninth weeks of gestation.

• Known teratogens include chemicals and drugs, infections, and radiation. The teratogenic potential of many chemicals and drugs is unknown, so pregnant women are usually advised to avoid all drugs if possible.

• Of the infectious agents, viruses are the most teratogenic, particularly organisms of the TORCH variety (toxoplasmosis, others, rubella, cyto- megalovirus, herpes virus).

114 UNIT II Cellular Function

serious implications for human evolution. There is also the potential for using the technology to create “new and improved” human beings or human clones.

Recombinant DNA Technology Over the past 30 years, DNA has gone from being the most difficult cellular molecule to study to being among the easiest. The great advances in molecular genetics during this time are due to plummeting costs of DNA sequencing and the development of recombinant DNA technologies. It is now possible to select a specific region of DNA, produce unlimited copies of it, determine its nucleotide sequence, use it to make unlimited quantities of a desired protein, or alter its DNA sequence at will (genetic engineering), and reinsert it into a living cell. Scientists can decipher the nucleotide sequence of an individual human genome, create DNA probes to explore an individual’s genetic makeup for specific mutations, mass-produce therapeutic proteins and vaccines, and hope someday to cure genetic disorders by replacing mutated genes with normally functioning ones.

Recombinant DNA technology comprises a number of techniques, the most important of which are briefly described here: • The long, difficult-to-handle DNA strands are more easily studied

if cut into smaller pieces. This is accomplished by using restriction enzymes that cleave DNA at specific sites. The resulting pieces can then be separated by electrophoresis according to their size. A section of DNA can be collected and efficiently sequenced by automated means.

• Nucleic acid hybridization techniques take advantage of the natural tendency for DNA and RNA to find and bind to a comple- mentary nucleotide sequence. A labeled piece of DNA or RNA can therefore be used to search for, or “probe” for, its complementary sequence among the many millions of sequences in a cell or cell extract. For example, in a fluorescence in situ hybridization (FISH) assay, a probe for a specific site on a chromosome is attached to a fluorescent label and incubated with a cell. The fluorescence is then examined to identify the location and number of copies of the particular chromosome sequence (Fig. 6.24). Without the hybridiza- tion technique, finding a desired gene among the 3 billion base pairs in the human genome could take many years of intense effort, like finding the proverbial needle in a haystack. Hybridization is also the method behind the “gene chip assay” technology. As an outcome of the Human Genome Project, the DNA sequences for the thousands of human genes and common mutations have been identified. Specific DNA sequence probes for these genes can be synthesized and attached to a fixed position on a plate (microchip). The DNA of interest can then be exposed to the chip, and the probes will preferentially bind to DNA segments having complementary bases. The position of the probe and the degree of DNA binding can then be analyzed by computer to produce a specific genetic analysis of gene mutations.

• DNA cloning is the technique used to produce many identical copies of a DNA sequence containing a gene of interest. The availability of large quantities of a purified gene sequence makes study and gene manipulation possible. A number of different techniques can be used to clone DNA. The PCR technique is very efficient if the DNA sequence is already partially known. Basically, the DNA sequence of interest is mixed with special DNA polymerases that use the DNA sequence as a template to produce double-stranded DNA. Each DNA thus produced can in turn act as a template for production of another DNA. Large quantities can be produced very rapidly by PCR. The DNA can also be cloned by inserting it into bacteria by use of a viral or plasmid vector. Bacteria that incorporate the desired gene are identified by hybridization with a labeled probe. The desired

Ultrasound and amniocentesis are mainstays of prenatal diagnostic examination. Ultrasound is a noninvasive procedure that uses sound waves to produce a reflected image of the fetus. It is commonly used to determine gestational age, fetal position, and placental location. Ultrasound is also useful in detecting visible congenital anomalies such as spina bifida (neural tube defect); heart defects; and malformations of the face, head, body, and limbs.

Amniocentesis may be performed to determine genetic and devel- opmental disorders not detectable by ultrasound. This invasive procedure is associated with a small but real risk of complications, including pregnancy loss. During amniocentesis, a needle is inserted through the abdomen or vagina and into the uterus. A sample of amniotic fluid containing skin cells shed by the fetus is removed for analysis. The amniotic fluid can be analyzed for abnormal levels of certain substances secreted by the fetus, such as α-fetoprotein, which may indicate neural tube defects. Fetal cells are also present in amniotic fluid and can be cultured and subjected to biochemical, chromosomal, and genetic analysis. Because amniocentesis is not recommended until at least 15 weeks’ gestation, it does not provide information until relatively late in the pregnancy. Chorionic villus sampling (CVS) involves the removal of a piece of tissue directly from the chorion (the outer membrane of the fetal sac). It can be performed after about 9 weeks’ gestation. Like amniocentesis, CVS is an invasive procedure that in rare instances results in pregnancy complication or loss.

Fetal cells obtained via either amniocentesis or CVS contain small amounts of DNA that can then be amplified into a larger quantity by a process called polymerase chain reaction (PCR). This DNA can then be analyzed by a variety of methods to determine the genetic sequence, the presence or absence of particular genes, or the presence of mutations. The fetal genome can be scanned for particular genes by exposing the processed DNA to microchips that are coated with thousands of genetic sequence probes in specific locations. Complementary base pairing between the probes fixed on the microchip and the DNA being tested is used to detect the presence of particular gene sequences.

In rare cases, a laparoscopic procedure may be performed to directly visualize the embryo or fetus. A fetoscope can be inserted through the cervix and into the uterus to identify and in some instances attempt to correct structural anomalies. The early diagnosis of congenital disorders allows a greater number of treatment options. Some disorders can be managed in utero; others may require early delivery, immediate surgery, or cesarean section to minimize fetal trauma. Early warning of fetal difficulties allows parents time to prepare emotionally for the birth of the child. In some instances, termination of the pregnancy may be the treatment of choice.

Genetic Analysis and Therapy An exciting promise in the genome era of health care remains on the horizon—the treatment of genetic disease by replacing a defective gene with a normal, healthy gene. The concept is simple, and clinical trials have been conducted to treat a number of genetic disorders. The first federally approved gene therapy procedure was performed in 1990 to treat a child who suffered from a particular type of severe combined immunodeficiency (SCID) by introducing a functional gene for the enzyme adenosine deaminase. In the past, children who suffered from SCID had severely compromised immune systems and generally died from overwhelming infections unless their environment was strictly controlled. Use of gene therapy has shown some success in improving immune function and allowing these children to live in the outside world, although the safety of gene therapy is a continuing challenge.

Gene therapy has the potential for alleviating human suffering by curing genetic diseases, but it is accompanied by a number of moral and ethical dilemmas. Tampering with the human gene pool could have

CHAPTER 6 Genetic and Developmental Disorders 115

thus elucidate the normal function of the original gene and its protein product. Genetic engineering has been applied to plants to increase their value as food crops. Genetically engineered bacteria are the source of more than 90 human proteins created in bacteria using recombinant DNA (rDNA) technology for pharmaceutical use; examples are human insulin, epoetin, and interferon. Gene therapy relies heavily on these techniques to facilitate identifica-

tion of genetic mutations, study of gene function, and development of methods to repair or replace mutated genes. Many more applications of rDNA technology will become apparent as research on the genetic basis of human function and disease proceeds.

KEY POINTS • Risk factors that indicate the need for prenatal diagnostic examination and

counseling include advanced maternal age (older than 35 years), a family history of genetic disorders, and the previous birth of a child with chromosomal or neural tube defects.

• Ultrasound, amniocentesis, and chorionic villus sampling (CVS) are the mainstays of prenatal assessment for genetic disorders. Technology for examining fetal DNA isolated from maternal blood has allowed some prenatal screening tests to be performed noninvasively.

• DNA sequences that are complementary to a gene of interest can be synthesized and used to probe a genome to determine whether and where the gene is present. These hybridization techniques make screening for genetic disorders relatively fast and simple.

• Gene therapy is the treatment of genetic disease by replacing defective genes with normal genes. Gene therapy is possible because of the advances attained in rDNA technology over the past 30 years.

FIG 6.24 Fluorescence in situ hybridization assay showing an interphase nucleus. The red probe is hybridized to chromosome 21 and the green probe is hybridized to chromosome 13. Three copies of chromosome 21 are identified, confirming the diagnosis of trisomy 21. (From Kumar V et al: Robbins & Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p. 161. Photograph courtesy Dr. Stuart Schwartz, Department of Pathology, University of Chicago, Chicago, IL.)

bacteria then are allowed to proliferate, making a copy of the DNA sequence along with their own genome with each cell division.

• Genetic engineering refers to a process whereby a gene of interest is altered from its original form. The altered (mutated) gene can be reintroduced into a cell to disclose its effect on cell function and

Genetic and developmental disorders are responsible for a number of congenital malformations. Congenital disorders are caused by genetic and environmental factors that disrupt normal fetal development. Genetic disorders are classified as (1) chromosomal alterations, including structural and numeric abnormalities; (2) mendelian disorders, including autosomal-dominant, autosomal-recessive, and X-linked disorders; (3) nonmendelian single-gene disorders, including triplet repeats, mito- chondrial gene defects, and genetic imprinting disorders; and (4) polygenic or multifactorial disorders. Known environmental teratogens include radiation, infectious organisms, and various chemicals and

drugs. The embryo is particularly susceptible to teratogens during the period of organogenesis, which extends from the third to the ninth week of gestation. Pedigree analysis, ultrasound, amniocentesis, and chorionic villus biopsy may provide helpful information regarding genetic risk and the prenatal condition of at-risk infants. DNA sequencing of normal and mutated genes has made it possible to efficiently screen for genetic disorders. DNA can be manipulated to produce human protein pharmaceuticals, and clinical trials to test gene therapies for a variety of genetic diseases have been conducted.

S U M M A R Y

RESOURCES Principles of Inheritance and Genetic Disorders Barry PJ, Jones AM: New and emerging treatments for cystic fibrosis. Drugs

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University Press. Down JHL: Observations on an ethnic classification of idiots. Clin Lect Rep

London Hosp 3:259–262, 1866. Jackson JM, Crider KS, Cragan JD, et al: Frequency of prenatal cytogenetic

diagnosis and pregnancy outcomes by maternal race-ethnicity, and the effect on the prevalence of trisomy 21, Metropolitan Atlanta, 1996-2005. Am J Med Genet 164A:70–77, 2014. doi:10.1002/ajmg.a.36247.

Jorde LB, Carey JC, Bamshad MJ: Medical genetics, ed 5, Philadelphia, 2016, Elsevier.

Kinch MS: An overview of FDA-approved biologics medicines. Drug Discov Today 20(4):393–398, 2015.

Koolwal A, Singh A: Ivacaftor: a novel mutation modulating drug. J Clin Diagn Res 8(22):SE1–SE5, 2014.

Kumar V, Abbas AK, Aster JC: Pathologic basis of disease, ed 9, Philadelphia, 2015, Elsevier Saunders.

Kumar S, Tana A, Shankar A: Cystic fibrosis—what are the prospects for a cure? Eur J Intern Med 25:803–807, 2014. doi:10.1016/j.ejim.2014.09 .018.

Lewis R: Human genetics: Concepts and applications, ed 11, New York, 2015, McGraw Hill.

116 UNIT II Cellular Function

Turnpenny P, Ellard S: Emery’s elements of medical genetics, ed 14, Philadelphia, 2012, Churchill-Livingstone.

Waldorf KMA, McAdams RM: Influence of infection during pregnancy on fetal development. Reproduction 146(5):R151–R162, 2013. doi:10.1530/ rep-13-0232.

Warby SC, Graham RK, Hayden MR: Huntington disease. In Pagon RA, Adam MP, Ardinger HH, et al, editors: GeneReviews [Internet], Seattle (WA), 1998 Oct 23 [Updated 2014 Dec 11]. University of Washington, Seattle, pp 1993–2015. Available from: http://www.ncbi.nlm.nih.gov/ books/NBK1305/.

Lewis RA: Oculocutaneous albinism Type 1. In Pagon RA, Adam MP, Ardinger HH, et al, editors: GeneReviews [Internet], Seattle (WA), 2000 Jan 19 [Updated 2013 May 16]. University of Washington, Seattle, pp 1993–2015. Available from: http://www.ncbi.nlm.nih.gov/books/ NBK1166/.

Macpherson JL, Rasko JEJ: Clinical potential of gene therapy: towards meeting the demand. Intern Med 44:224–233, 2014. doi:10.1111/imj.12366.

Senturias YSN: Fetal alcohol spectrum disorders: an overview for pediatric and adolescent care providers. Curr Probl Pediatr Adolesc Health Care 4(44):74–81, 2014. doi:10.1016/j.cppeds.2013.12.012.

117

7

Neoplasia Jacquelyn L. Banasik

K E Y Q U E S T I O N S • How do neoplastic cells differ from normal cells? • In what ways do benign and malignant tumors differ? • How might overexpression of proto-oncogenes lead to abnormal

cellular proliferation? • How might underexpression of tumor suppressor genes lead to

abnormal cellular proliferation? • What properties are gained during tumor progression that

contribute to malignant behavior and metastasis?

• How are tumor grading and staging used to characterize cancers and guide the selection of cancer therapies?

• How might lifestyle and carcinogen exposure contribute to cancer risk?

• What effects does cancer have on the body? • What options are available for cancer treatment?

C H A P T E R O U T L I N E Benign Versus Malignant Growth, 118

Characteristics of Benign and Malignant Tumors, 118

Tumor Terminology, 118

The Malignant Phenotype, 118

Epidemiology and Cancer Risk Factors, 120 Tobacco Use, 120

Nutrition, 120

Antioxidants, 123

Genetic Mechanisms of Cancer, 123 Proto-Oncogenes, 124

Growth Factors (Mitogens), 124 Growth Factor Receptors, 124 Cytoplasmic Signaling Pathways, 124 Transcription Factors, 125 From Proto-Oncogene to Oncogene, 125

Tumor Suppressor Genes, 127

The Rb Gene, 127 The P53 Gene, 128 BRCA1 and BRCA2 Genes, 128

Multistep Nature of Carcinogenesis, 129 Initiation, 129

Promotion, 131

Progression, 131

Metastasis, 132 Patterns of Spread, 132

Angiogenesis, 133

Grading and Staging of Tumors, 134

Effects of Cancer on the Body, 136 Cancer Therapy, 137

Surgery, 137

Radiation Therapy, 138

Drug Therapy, 138

Immunotherapy, 138

Gene and Molecular Therapy, 138

Stem Cell Transplantation, 139

http://evolve.elsevier.com/Banasik/pathophysiology/

Neoplasia means “new growth.” In common use, the term implies an abnormality of cellular growth and may be used interchangeably with the term tumor. It is no surprise that the discovery of a tumor in an individual can evoke feelings of disbelief, anger, and dread. Characteriza- tion of the tumor cells is of critical importance to determine whether the tumor is benign or malignant. The term cancer is applied only to malignant neoplasms. The diagnosis of a benign growth is received with great relief inasmuch as the tumor is generally easily cured. The

diagnosis of a malignant cancer, on the other hand, may involve months of intensive and often uncomfortable treatment with uncertain outcomes. Cancer remains the second-leading cause of death in the United States for both men and women.

It is increasingly clear that cancer is associated with altered expression of cellular genes that normally regulate cell proliferation and differentia- tion. A unified theory of cancer causation has emerged, and new methods for cancer therapy continue to be developed. Cancer is a complex,

• Review Questions and Answers • Glossary (with audio pronunciations for selected terms) • Animations

• Case Studies • Key Points Review

118 UNIT II Cellular Function

Tumor Terminology General rules for the naming of tumors have been developed to indicate the tissue of origin and the benign or malignant nature of the tumor. The suffix -oma is used to indicate a benign tumor, whereas carcinoma and sarcoma are used to indicate malignant tumors. Carcinoma refers to malignant tumors of epithelial origin and sarcoma to malignant tumors of mesenchymal (nerve, bone, muscle) origin. Thus a benign tumor of glandular tissue would be called an adenoma, but a malignant tumor of the same tissue would be called an adenocarcinoma (Table 7.2). Some notable exceptions to the rules are lymphomas, hepatomas, and melanomas, which are all highly malignant despite their -oma suffix. Leukemia refers to a malignant growth of white blood cells. The great majority of human cancers (90%) are carcinomas from malignant transformation of epithelial cells.

The Malignant Phenotype Cells growing in normal tissue have predictable relationships with neighboring cells. In a particular tissue, the rate of cell proliferation is precisely matched to the rate of cell death. Normal cells require constant reassurance in the form of survival signals from their environment that their continued existence is desirable, and they proliferate only when space is available and appropriate mitogen-stimulating signals are present.

multifaceted disorder, with each individual cancer having some unique properties. A better understanding of the molecular characteristics of individual cancers is encouraging the development of specific therapies that target each cancer’s weaknesses.

BENIGN VERSUS MALIGNANT GROWTH Characteristics of Benign and Malignant Tumors The terms benign and malignant refer to the overall consequences of a tumor to the host. Generally, malignant tumors have the potential to kill the host if left untreated, whereas benign tumors do not. This difference is not strict because some benign tumors may be located in critical areas. For example, a benign tumor may be life threatening if it causes pressure on the brain or blocks an airway or blood vessel. Histologic examination of a tumor is the primary mode for determining its benign or malignant nature. Certain tumor characteristics have historically been shown to indicate malignant potential. Important considerations include localization of the tumor and determination of the degree of tumor cell differentiation.

Benign tumors do not invade adjacent tissue or spread to distant sites. Many benign tumors are encapsulated by connective tissue, which is an indication of strictly local growth. Any evidence that tumor cells have penetrated local tissues (invasiveness), lymphatics, or blood vessels suggests a malignant nature with potential to spread to distant sites (metastasize).

As a general rule, benign cells more closely resemble their tissue type of origin (e.g., skin, liver) than do malignant cells. The degree of tissue-specific differentiation has traditionally been used to predict malignant potential. A lack of differentiated features in a cancer cell is called anaplasia, and a greater degree of anaplasia is correlated with a more aggressively malignant tumor. Anaplasia is indicated by variation in cell size and shape within the tumor, enlarged nuclei, abnormal mitoses, and bizarre-looking giant cells (Fig. 7.1). Regardless of histologic appearance, invasion of local tissue or evidence of metastasis to distant sites confirms the diagnosis of malignancy.

Other differences between benign and malignant tumors have been noted (Table 7.1). Benign tumors generally grow more slowly, have little vascularity, rarely have necrotic areas, and often retain functions similar to those of the tissue of origin. Conversely, malignant tumors often grow rapidly and may initiate vessel growth in the tumor. They frequently have necrotic areas and are dysfunctional.

A B

FIG 7.1 A, Normal Papanicolaou smear from the uterine cervix showing large, flat epithelial cells with small nuclei. B, Typical histologic appearance of anaplastic tumor cells showing variation in cell size and shape, with large, hyperchromic nuclei. (From Kumar V et al: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p 1006. Courtesy Edmund S. Cibas, Brigham and Women’s Hospital, Boston, MA.)

TABLE 7.1 General Characteristics of Benign and Malignant Tumors

Characteristic Benign Malignant

Histology Typical of tissue of origin

Few mitoses

Anaplastic, with abnormal cell size and shape

Many mitoses Growth rate Slow Rapid Localization/

metastasis Strictly local, often

encapsulated/no metastasis

Infiltrative/frequent metastases

Tumor necrosis Rare Common Recurrence after

treatment Rare Common

Prognosis Good, unless in critical area

Poor if untreated

CHAPTER 7 Neoplasia 119

original stem cell properties and the other becoming a more differentiated cell, but still capable of proliferation. Normally, the partially differentiated cells can undergo only a limited number of cell divisions before they permanently leave the cell cycle and become senescent. Either a stem cell or a partially differentiated cell has the potential to acquire the genetic mutations necessary to become malignant.

Normal cells also respond to signals instructing them to actively destroy themselves in a process called apoptosis (see Chapter 4). Cancer cells, however, do not obey the rules; they have escaped the normal mechanisms of growth control. A number of antisocial properties develop in malignant cells that allow them to proliferate at the expense of other cells and tissues of the body. These abnormal behaviors can be summarized as follows: • Cancer cells proliferate despite lack of growth-initiating signals from

the environment. • Cancer cells escape apoptotic signals and achieve a kind of immortality

in that they are capable of unlimited replication. • Cancer cells lose their differentiated features and contribute poorly

or not at all to the function of their tissue. • Cancer cells are genetically unstable and evolve by accumulating

new mutations at a much faster rate than normal cells. • Cancer cells invade their local tissue and overrun their neighbors. • Perhaps worst of all, cancer cells gain the ability to migrate from

their site of origin to colonize distant sites where they do not belong. Most cancers are thought to arise from stem cells that are present

in tissues. Tissue stem cells are capable of proliferation, entering the cell cycle to produce two daughter cells—with one cell retaining the

TABLE 7.2 Nomenclature for Neoplastic Diseases

Cell or Tissue of Origin Benign Malignant

Tumors of Epithelial Origin Squamous cells Squamous cell papilloma Squamous cell carcinoma Basal cells — Basal cell carcinoma Glandular or ductal epithelium Adenoma Adenocarcinoma

Cystadenoma Cystadenocarcinoma Transitional cells Transitional cell papilloma Transitional cell carcinoma Bile duct Bile duct adenoma Bile duct carcinoma (cholangiocarcinoma) Liver cells Hepatocellular adenoma Hepatocellular carcinoma Melanocytes Nevus Malignant melanoma Renal epithelium Renal tubular adenoma Renal cell carcinoma Skin adnexal glands Sweat glands Sweat gland adenoma Sweat gland carcinoma Sebaceous glands Sebaceous gland adenoma Sebaceous gland carcinoma Germ cells (testis and ovary) — Seminoma (dysgerminoma), embryonal carcinoma, yolk sac carcinoma

Tumors of Mesenchymal Origin Hematopoietic/lymphoid tissue — Leukemia, lymphoma, Hodgkin disease, multiple myeloma Neural and retinal tissue Nerve sheath Neurilemmoma, neurofibroma Malignant peripheral nerve sheath tumor Nerve cells Ganglioneuroma Neuroblastoma Retinal cells (cones) — Retinoblastoma Connective tissue Fibrous tissue Fibromatosis (desmoid) Fibrosarcoma Fat Lipoma Liposarcoma Bone Osteoma Osteogenic sarcoma Cartilage Chondroma Chondrosarcoma Muscle Smooth muscle Leiomyoma Leiomyosarcoma Striated muscle Rhabdomyoma Rhabdomyosarcoma Endothelial and related tissues Blood vessels Hemangioma Angiosarcoma

Kaposi sarcoma Lymph vessels Lymphangioma Lymphangiosarcoma Synovium — Synovial sarcoma Mesothelium — Malignant mesothelioma Meninges Meningioma Malignant meningioma

KEY POINTS • Malignant tumors have the potential to kill the host, whereas benign tumors

generally do not. The primary difference between malignant and benign tumors is the propensity of malignant tumors to invade adjacent tissue and spread to distant sites (metastasize).

• The suffix -oma is used to indicate a benign tumor (e.g., fibroma). Carcinoma and sarcoma are used to indicate malignancy (e.g., fibrosarcoma). Exceptions include melanomas, lymphomas, hepatomas, and leukemia, all of which are malignant.

• Malignant cells exhibit antisocial properties that allow them to ignore growth-controlling signals from the environment. Cancer cells proliferate excessively, become immortal, invade locally, and may travel to distant sites where they establish new colonies.

120 UNIT II Cellular Function

1998 (Fig. 7.3). Whereas all other cancer-related death rates declined or remained relatively stable, the death rate from lung cancer increased dramatically. The increase is attributable almost entirely to smoking. Lung cancer remains the leading cause of cancer death in both men and women, accounting for nearly 30% of all cancer deaths. Lung cancer has one of the worst survival rates of all cancers—only 15%. In addition to lung cancer, tobacco use has been linked with cancer of the pancreas, bladder, kidney, mouth, esophagus, and cervix (Fig. 7.4). Smoking prevalence among adults in the United States declined from 42% in 1965% to 18% in 2013, with rates being approximately 5% lower in women than in men. An estimated 42 million U.S. adults currently smoke cigarettes. Approximately 16% of high school students reported being cigarette smokers in 2013. Approximately 2% of adults use electronic nicotine devices (e-cigarettes). There is little known about the relative risk of these products compared with traditional tobacco.

Carcinogens can be grouped into two major types: those that cause genetic damage (initiators) and those that promote growth of the tumor (promoters). Tobacco smoke contains hundreds of compounds, many of which have known genotoxicity (e.g., polycyclic aromatic hydrocarbons, nicotine derivatives) and probably serve as initiators. Tobacco smoke also contains promoters, which spur the mutant cells to proliferate.

Nutrition The scientific study of nutrition and cancer is complex, and it is not clear how single nutrients, combinations of nutrients, overnutrition

EPIDEMIOLOGY AND CANCER RISK FACTORS Cancer accounts for approximately 25% of all deaths, which makes it the second-leading cause of death in the United States. Most cancer deaths (78%) occur in persons older than 55 years. The American Cancer Society (ACS) estimates that men have almost a 1 in 2 lifetime risk of developing cancer and women have slightly higher than a 1 in 3 risk. The 5-year relative survival rate for all cancers combined is about 68%. The 5-year survival rate does not distinguish between those who were cured and those who have relapsed or are still in treatment. Fortunately, the current view of cancer causation predicts that many cancers are preventable. Indeed, one-third of cancer-related deaths may be attributed to lifestyle factors. Lifestyle factors of particular importance are tobacco use and nutrition. Sun exposure is a significant risk factor for skin cancer (Chapter 53), and sexual exposure to certain strains of human papillomavirus predisposes to cervical cancer (Chapter 34). The high incidence and relative ease of screening for breast, cervical, colorectal, and prostate cancers have prompted the development of guidelines for early detection of these cancers. The current recommendations for early detection of cancer in average-risk, asymptomatic persons are shown in Table 7.3. Statistics regarding some of the major forms of cancer are shown in Fig. 7.2. Further discussions of particular cancers can be found in chapters relating to corresponding body systems.

Tobacco Use The impact of tobacco use on cancer-related death can be most vividly seen by looking at cancer death rates in the United States from 1930 to

Men 312,150

Women 277, 280

Men 848,200

Women 810,170

26% Lung and bronchus

15% Breast

9% Colon and rectum

5% Ovary

7% Pancreas

4% Leukemia

3% Non-Hodgkin lymphoma

4% Uterine corpus

3% Liver and intrahepatic bile duct

2% Brain/other nervous system

22% All other sites

Lung and bronchus 28%

Prostate 9%

Colon and rectum 8%

Pancreas 7%

Leukemia 5%

Non-Hodgkin lymphoma 4%

Esophagus 4%

Liver and intrahepatic bile duct

5%

Urinary bladder 4%

Kidney 3%

All other sites 23%

29% Breast

13% Lung and bronchus

8% Colon and rectum

7% Uterine corpus

3% Leukemia

4% Non-Hodgkin lymphoma

4% Melanoma of skin

6% Thyroid

3% Kidney

3%

20% All other sites

Prostate 26%

Lung and bronchus 14%

Colon and rectum 8%

Urinary bladder 7%

Melanoma of skin 5%

Non-Hodgkin lymphoma 5%

Kidney 5%

Oral cavity 4%

Leukemia

Pancreas

4%

Liver 3%

All other sites 19%

A

B

FIG 7.2 United States 2015 estimated new cancer cases (A) and estimated cancer deaths (B) in 10 leading sites by gender. Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. (Data from American Cancer Society: Cancer facts and figures—2015, Atlanta, GA, 2015, American Cancer Society.)

CHAPTER 7 Neoplasia 121

TABLE 7.3 Screening Guidelines for the Early Detection of Cancer in Average-Risk Asymptomatic People

Cancer Site Population Test or Procedure Frequency

Breast Women, age 20+ Breast self- examination (BSE)

It is acceptable for women to choose not to do a BSE or to do a BSE regularly (monthly) or irregularly. Beginning in their early 20s, women should be told about the benefits and limitations of BSE. Whether a woman ever performs a BSE, the importance of prompt reporting of any new breast symptoms to a health professional should be emphasized. Women who choose to do BSE should receive instruction and have their technique reviewed on the occasion of a periodic health examination.

Clinical breast examination (CBE)

For women in their 20s and 30s, it is recommended that CBE be part of a periodic health examination, preferably at least every 3 years. Asymptomatic women aged 40+ should continue to receive a CBE as part of a periodic health examination, preferably annually.

Mammography Begin annual mammography at age 40* Cervix Women, age

21–65 Pap test and HPV DNA

test Cervical cancer screening should begin at age 21. For women ages 21–29, screening should be

done every 3 years with conventional or liquid-based Pap tests. For women ages 30–65, screening should be done every 5 years with both HPV test and the Pap test (preferred), or every 3 years with the Pap test alone (acceptable). Women ages 65+ who have had ≥3 consecutive negative Pap tests or ≥2 consecutive negative HPV and Pap tests within the last 10 years, with the most recent test occurring within 5 years, and women who have had a total hysterectomy should stop cervical cancer screening. Women should not be screened annually by any method at any age.

Colorectal Men and women, age 50+

Fecal occult blood test (FOBT) with at least 50% test sensitivity for cancer, fecal immunochemical test (FIT) with at least 50% test sensitivity for cancer, or

Annual, starting at age 50. Testing at home with adherence to manufacturer’s recommendation for collection techniques and a number of samples is recommended. FOBT with single stool sample collected on the clinician’s fingertip during a DRE in the health care setting is not recommended. Guaiac-based toilet bowl FOBT tests are also not recommended. In comparison with the guaiac-based tests for the detection of occult blood, immunochemical tests are more patient friendly and are likely to be equal or better in sensitivity and specificity. There is no justification for repeating FOBT in response to an initial positive finding.

Stool DNA test, or Every 3 years, starting at age 50 Flexible sigmoidoscopy

(FSIG), or Every 5 years, starting at age 50. FSIG can be performed alone, or consideration can be given

to combining FSIG performed every 5 years with a highly sensitive guaiac-based FOBT or FIT performed annually.

Double-contrast barium enema (DCBE), or

Every 5 years, starting at age 50

Colonoscopy Every 10 years, starting at age 50 CT Colonography Every 5 years, starting at age 50

Endometrial Women, at menopause

At the time of menopause, women at average risk should be informed about risks and symptoms of endometrial cancer and strongly encouraged to report any unexpected bleeding or spotting to their physicians.

Lung Current or former smokers (quit within the past 15 years) ages 55–74 in good health with at least a 30 pack-year history

Low-dose helical CT (LDCT)

Clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with apparently healthy patients aged 55–74 who have at least a 30 pack-year smoking history and who currently smoke or have quit within the last 15 years. A process of informed and shared decision making with a clinician related to the potential benefits, limitations, and harms associated with screening for lung cancer with LDCT should occur before any decision is made to initiate lung cancer screening. Smoking cessation counseling remains a high priority for clinical attention in discussions with current smokers, who should be informed of their continuing risk of lung cancer. Screening should not be reviewed as an alternative to smoking cessation.

Prostate Men, age 50+ Digital rectal examination (DRE) and prostate-specific antigen test (PSA)

Men who have at least 10-year life expectancy should have an opportunity to make an informed decision with their health care provider about whether to be screened for prostate cancer, after receiving information about the potential benefits, risks, and uncertainties associated with prostate cancer screening. Prostate cancer screening should not occur without an informed decision-making process.

Cancer-related checkup

Men and women age 20+

On the occasion of a periodic health examination, the cancer-related checkup should include examination for cancers of the thyroid, testicles, ovaries, lymph nodes, oral cavity, and skin, as well as health counseling about tobacco, sun exposure, diet and nutrition, risk factors, sexual practices, and environmental and occupational exposures.

American Cancer Society: Cancer prevention and early detection facts and figures—2015–2016, Atlanta, GA, 2015, American Cancer Society. CT, computed tomography. *Beginning at age 40, annual clinical breast examination should ideally be performed before mammography.

122 UNIT II Cellular Function

Year of Death

Male Death Rates for Cancer of the Lung, Bronchus, Trachea, and Pleura

Female Death Rates for Cancer of the Lung, Bronchus, Trachea, and Pleura

Age at Death R

a te

p e r

1 0 0 ,0

0 0

1930–34

200

100

0

300

400

500

600

700

1940–44 1950–54 1960–64 1970–74 1980–84 1990–94

85+ (1940–98) 80–84 (1940–98) 75–79 (1940–98) 70–74 65–69 60–64 55–59 50–54 45–49 40–44 35–39 30–34

Age at Death

85+ (1940–98) 80–84 (1940–98) 75–79 (1940–98) 70–74 65–69 60–64 55–59 50–54 45–49 40–44 35–39 30–34

Year of Death

R a te

p e r

1 0 0 ,0

0 0

1930–34

100

50

0

150

200

250

300

1940–44 1950–54 1960–64 1970–74 1980–84 1990–94

A

B FIG 7.3 Death rates for cancer of the lung, bronchus, trachea, and pleura, by age at and year of death, 1930–1998. A, Male death rates. B, Female death rates. (Data From U.S. Department of Commerce, Bureau of the Census. Mortality statistics. Washington: U.S. Government Printing Office, 1930–1936; U.S. Department of Commerce, Bureau of the Census. Vital statistics of the United States, Part I. Washington: Government Printing Office, 1937–1944; Federal Security Agency, Public Health Service, National Office of Vital Statistics. Vital statistics of the United States, Part I. Washington: Government Printing Office, 1945–1949; U.S. Depart- ment of Health, Education, and Welfare, Public Health Service, National Office of Vital Statistics. Vital statistics of the United States. Volume II. Washington: Government Printing Office, 1950–1959; Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple cause of death public use data files. Hyattsville, MD: National Center for Health Statistics, 1960–1998.)

CHAPTER 7 Neoplasia 123

GENETIC MECHANISMS OF CANCER Despite much progress in our understanding of how mechanisms of growth control and cellular differentiation may go awry, there is still no simple answer to the question, “What causes cancer?” It is increasingly evident, however, that cancer is primarily a disorder of gene expression. Early support for a genetic basis of cancer came from the observation that cancer often resulted from agents known to damage DNA. In the 1970s a number of potential cancer-causing agents (carcinogens) were identified by demonstrating their mutagenic potential. The suggestion that mutant genes were the basis for cancer launched intense research to identify the cancer-causing gene or genes.

Cancer-critical genes are grouped into two broad classes, according to whether overactivity of the gene contributes to cancer (gain-of-function mutations) or whether underactivity is the problem (loss-of-function mutations). Both categories of genes result in similar effects in enhancing cell proliferation and survival. Genes in the first category are called proto-oncogenes, which normally code for components of the cellular growth–activating pathways. A proto-oncogene in its mutant, overactive, or overexpressed form is called an oncogene. Genes in the second category of cancer-related genes are called tumor suppressor genes, which normally inhibit cell proliferation. Cancers may arise when tumor suppressor

and energy imbalance, or the amount and distribution of body fat affect a person’s risk for specific cancers. The ACS suggests a mostly plant-based diet emphasizing a variety of vegetables, fruits, and whole grains. The ACS endorses limiting the intake of red and processed meats while controlling total caloric intake to maintain a healthy weight and avoiding excessive alcohol intake. Alcohol intake has been linked to a number of cancers, including breast, esophageal, laryngeal, and liver cancer. Alcohol may exert its cancer-promoting effects through impairment of the liver’s ability to metabolize harmful substances and endogenous hormones. Moderate alcohol intake has been shown to increase estrogen levels, which may account for its promoting effects on breast cancer. As a carbohydrate-dense sub- stance, alcohol may contribute to cancer risk through its effects on insulin secretion. Insulin is a general growth factor for a number of tissues. Limiting alcohol intake may provide a modest reduction in cancer risk.

Antioxidants The emphasis of cancer prevention generally has been on the identifica- tion and avoidance of cancer-causing agents. However, increasing interest has been shown in finding substances with cancer-protective properties. The fact that DNA damage is an important step in cancer initiation, coupled with the knowledge that oxygen free radicals can impart this damage, led to the idea that antioxidants may have protective effects for cancer. The specific agents tested in clinical trials included β-carotene, vitamin E, vitamin C, selenium, retinol, zinc, riboflavin, and molybdenum. None of the completed trials produced convincing evidence to justify the use of traditional antioxidant-related vitamins or minerals for cancer prevention.

Vitamin A and the antioxidant trio of vitamin E, β-carotene, and vitamin C have been most widely studied. The use of antioxidants to prevent cancer sounds like a good idea; however, several large-scale studies have failed to reveal a benefit, and some have found that the risk of cancer may be increased. At present, it may be prudent to consume a diet high in natural fruit and vegetable sources of antioxidants.

KEY POINTS • The risk of developing cancer increases with age. It is estimated that men

have almost a 1 in 2 lifetime chance of developing cancer, whereas women have a little more than a 1 in 3 chance.

• The development of many cancers is related to lifestyle, particularly tobacco use and nutrition. Smoking cessation is considered important in reducing cancer risk. Guidelines regarding nutrition are less clear; however, avoiding excess weight gain is recommended. Limiting excessive calorie and alcohol intake while increasing intake of dietary fiber, fruit, and vegetables may be of benefit.

C a n

c e r

s it

e

Oropharynx

Number of deaths (in thousands)

Male

20 40 60 80 1000

Larynx

Esophagus

Stomach

Pancreas

Lung

Bladder

Kidney

Myeloid leukemia

C a n

c e r

s it

e

Oropharynx

Number of deaths (in thousands)

Female

20 40 60 80 1000

Larynx

Esophagus

Stomach

Pancreas

Cervix

Lung

Bladder

Kidney

Myeloid leukemia

Attributable to cigarette smoking

Other causes

Attributable to cigarette smoking

Other causes

FIG 7.4 Annual cancer deaths attributable to smoking in males and females in the United States. (From Centers for Disease Control and Prevention: Annual smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 2000-2004, MMWR Morb Mortal Wkly Rep 2008;57(45):1226–1228.)

124 UNIT II Cellular Function

gene function is lost or abnormally inhibited. To achieve malignant transformation, a cell must generally suffer mutations in a combination of these growth regulatory genes. A cell thus transformed passes on these mutations to its progeny when it divides and forms a clone of abnormally proliferating cells. Numerous studies have begun to unravel the details of how proto-oncogenes and tumor suppressor genes may dysfunction and contribute to the malignant phenotype. In addition to the genes that regulate the cell cycle, two other categories of genes that monitor and maintain the genome contribute indirectly to the development of cancer. These are the DNA-repair genes and the genes that regulate apoptosis (see Chapter 4).

Proto-Oncogenes Proto-oncogenes were the first of the tumor-associated genes to be discovered, and hundreds have been described to date. As often happens in the study of genes, a gene associated with a disease process is identified long before its normal cellular function is elucidated. Thus genes associated with cancer are traditionally named for the cancer in which they were first discovered (in mutant form) rather than for their normal cellular function. Many of the first cancer-associated genes, called oncogenes, were initially identified in viruses and still retain the name reflecting their viral discovery. The term proto-oncogene was created to label the normal cellular gene that can be transformed into an oncogene by activating (gain-of-function) mutations. A representative list of known proto-oncogenes is shown in Table 7.4.

The majority of proto-oncogenes described to date code for com- ponents of cell-signaling systems that promote cell proliferation. These

TABLE 7.4 Examples of Gain-of-Function Proto-Oncogenes and Their Mechanisms of Action

Factor Type of Cancer

Mitogens and Growth Factors PDGF Glioma (brain) FGF Melanoma EGF Breast TGF-α Breast, numerous others

Cell Membrane Receptors ERBB1 (EGF receptor) Breast, brain HER-2 (ERBB2) Breast, ovarian RET Thyroid

Cytoplasmic Signaling Molecules RAS Lung, ovarian, colon, pancreatic, leukemia ABL Leukemia JAK2 Myeloproliferative, leukemia

Transcription Factors and Cell Cycle Regulators C-MYC Leukemia, breast, lung, neuroblastoma MYB Various JUN Various FOS Various REL Various Cyclin D, E Breast, lymphoma Cyclin-dependent kinase 4 Melanoma, sarcoma

EGF, Epidermal growth factor; FGF, fibroblast growth factor; PDGF, platelet-derived growth factor; TGF, transforming growth factor.

components can be grouped into four broad categories: (1) growth factors, (2) receptors, (3) cytoplasmic signaling molecules, and (4) nuclear transcription factors (Fig. 7.5). Excessive activity in any of these components may release the cell from environmental feedback and allow it to proliferate abnormally.

Growth Factors (Mitogens) The first proto-oncogenes to be discovered coded for growth factors. A great deal of intercellular communication is accomplished through the cell-to-cell transmission of growth factors. Growth factors are small peptides that are manufactured by cells and secreted into the extracellular space. They diffuse to nearby cells and interact with receptors on the target cell surface. Binding of growth factors to cell surface receptors activates signaling cascades within the cell that enhance proliferation. As a general principle, cells do not independently produce growth factors sufficient to stimulate their own proliferation. The proliferation signals must be produced by the cell’s environment. The cell’s environment also conveys growth-inhibiting signals. Overproduction of stimulatory growth factors by a mutant proto-oncogene can shift the balance of signals and produce excessive self-stimulated growth (autocrine signaling). Examples of tumor-secreted growth factors include platelet-derived growth factor (PDGF), transforming growth factor-α (TGF-α), and epidermal growth factor (EGF). Certain cancer types typically secrete particular growth factors. For example, PDGF is commonly oversecreted in glial cell cancers (brain tumors) and connective tissue cancers (sarcomas).

Growth Factor Receptors Peptide growth factors (mitogens) cannot penetrate the cell membrane directly, so their presence at the cell surface must be transmitted intracel- lularly by cell surface receptors. Receptors are transmembrane proteins with the mitogen-binding area on the outside of the cell and an enzyme- activating area on the inside of the cell. These receptors are extremely specific; they will bind with only one particular mitogen. Binding activates a series of reactions within the cell that eventually leads to cell proliferation.

A mutational event may allow the expression of receptors that should not be present at all or allow excessive amounts of normally present receptors, or it may produce receptors with abnormally high affinity. All of these changes result in excessive responsiveness to the mitogens normally present in the cell’s environment. Some mutant receptors may even be active in the absence of growth factors and spur the cell to divide despite the absence of environmental signals to do so. An important example of a receptor abnormality is the overexpression of human epidermal growth factor receptor type 2 (HER2) receptors in about 25% of breast cancers. The overactive receptors stimulate proliferation of tumor cells even when there is little or no epidermal growth factor bound to them.

Cytoplasmic Signaling Pathways A third way in which oncogenes may facilitate proliferation is by the manufacture of excessive or abnormal components of the intracellular signaling pathways. These pathways involve numerous enzymes and chemicals that normally function to transmit signals from activated receptors at the cell surface to the cell nucleus. A mutant proto-oncogene that codes for excessive or abnormal cytoplasmic signaling components could cause activation of the pathway even though no signal was received at the cell surface. A well-understood example of this mechanism is mutations of the ras gene family. Proteins encoded by ras genes are monomeric G-proteins that transmit signals from receptors at the cell surface into the interior of the cell. The ras protein is active when it has guanosine triphosphate (GTP) bound to it, but it quickly hydrolyzes the GTP, thus automatically turning itself off after a brief period of

CHAPTER 7 Neoplasia 125

activity. A mutation in the ras gene can code for a protein that is unable to hydrolyze GTP, so it remains persistently active and stimulates cell proliferation inappropriately. Mutations of the ras genes occur in about 20% of all human cancers, including leukemias and lung, ovarian, colon, and pancreatic cancer.

Transcription Factors The entire proliferation pathway, including the growth factor (mitogen), the receptor, and the intracellular cascade, ultimately affects transcription of a set of genes in the nucleus that spur the cell to enter the S phase. A number of proto-oncogenes have been identified that code for transcription factors in the nucleus. Transcription factors are proteins that must be assembled at the promoter area to begin gene transcription (see Chapters 3 and 5). Transcription factors are normally sequestered and prevented from indiscriminate activity until appropriate signals cause their release. Mutations in transcription factor genes may cause overproduction of transcription factors or interfere with the normal mechanisms for keeping them in check. Myc, jun, and fos are examples of proto-oncogenes that code for nuclear transcription factors. Abnor- malities of the myc genes are found in numerous cancers, including lung and breast cancer, leukemia, and neuroblastoma.

From Proto-Oncogene to Oncogene Proto-oncogenes become activated oncogenes when mutations alter their activity so that proliferation-promoting signals are generated inappropriately. At least four general ways in which proto-oncogenes can be activated are known (Fig. 7.6): (1) oncogenes may be introduced into the host cell by a retrovirus; (2) a proto-oncogene within the cell may suffer a mutagenic event that changes its structure and function; (3) a DNA sequence that normally regulates proto-oncogene expression may be damaged or lost and allow the proto-oncogene to become abnormally active; and (4) an error in chromosome replication may cause extra copies of the proto-oncogene to be included in the genome (amplification).

In the early 1960s it was discovered that certain viruses were associated with cancer in various animal models. Researchers speculated that a virus could introduce a mutant, cancer-causing gene (oncogene) into the host’s cells. Indeed, malignant cells containing the cancer-causing viruses were shown to have incorporated a small number of viral genes into their cellular DNA. The presence of these oncogenes was required to maintain the malignant state of the cell.

Only a few types of human cancers are thought to be associated with viruses (Table 7.5). For example, human immunodeficiency virus is associated with Kaposi sarcoma, Epstein-Barr virus with Burkitt lymphoma, and human T-lymphocyte virus type I with adult T-cell leukemia-lymphoma. Viruses can interrupt normal cell growth control pathways and interfere with apoptotic pathways. Sometimes viruses incorporate into the host cell’s genome and disrupt gene regulation. See Chapter 8 for a review of viral mechanisms.

Proto-oncogene expression is tightly regulated in a normal cell. A number of different mutations can affect proto-oncogene expression and activity. A point mutation in the coding region of the proto-oncogene can alter the structure of its protein product and make it hyperactive. An example of this mechanism is the abnormal ras protein described earlier. Even though the protein is synthesized in normal quantity, its activity is enhanced. Other mutations may lead to overproduction of a protein with normal structure. Gene amplification and chromosomal rearrangement during mitosis may release the proto-oncogene from its normal regulation and allow excessive transcription (Fig. 7.7).

In summary, mutational events in the cell’s genome may cause overexpression of normal proto-oncogene products or production of altered and hyperactive proteins. Most known oncogenes act by releasing

Abnormal growth factor

A

Abnormal growth factor receptors

B

Abnormal intracellular pathway components

C

Abnormal transcription factors

D FIG 7.5 Possible effects of proto-oncogene activation on growth signaling pathways. A, Production of growth factors (mitogens). B, Production of growth factor receptors. C, Intracellular pathway disturbances. D, Activa- tion of transcription factors for growth.

126 UNIT II Cellular Function

Inserted viral

oncogene

Activated proto-

oncogene

Activated proto-oncogene

Mutation of regulatory sequence

Chromosome

Retrovirus

Viral RNA

Viral DNA RT

Mutagenic event

Mutagenic event

Amplification of

proto-oncogene

B

D

A

C

FIG 7.6 Mechanisms of proto-oncogene activation. A, Retroviral insertion. B, Proto-oncogene mutation. C, Regulatory sequence mutation. D, Proto-oncogene amplification. RT, Reverse transcriptase.

DNA

Gene

Excessive production of normal protein

Normal amount of hyperactive protein

Point mutation

Ge ne

am pli

fic ati

on

Chromosome rearrangement

Normal gene product

Excessive production of normal protein

FIG 7.7 Overactivity of proto-oncogenes may be due to normal production of an abnormal protein (mutation in coding sequence) or excessive production of a normal protein (gene amplification or chromosome rearrangement).

CHAPTER 7 Neoplasia 127

of the eye. A familial form of retinoblastoma is associated with the transmission of a genetic defect; a portion of chromosome 13 is missing, which is where the Rb gene is normally located. An absent Rb gene predisposes an individual to cancer, but cancer will not develop unless the other copy of the Rb gene (from the other parent) is also damaged (Fig. 7.8).

Since the initial discovery of the Rb tumor suppressor gene, researchers have compiled an impressive list of other genes that appear to function as inhibitors of cellular proliferation (Table 7.6). As with the Rb gene, both copies of the tumor suppressor genes usually are inactivated when cancer develops. A person who inherits a defective copy of a tumor suppressor gene from one parent has a much higher risk of cancer than a person who inherits two healthy copies. Knowledge about the sequence of many of these genes provides the opportunity to screen individuals with familial cancers to determine whether they carry a defective gene. Detection of defective tumor suppressor genes is easier than determining their normal cellular functions, but steady progress is being made.

Why do tumor suppressor genes stop functioning? As with proto-oncogene activation, genetic mutations are the usual culprits. Chromosome deletions, point mutations, or chromosome loss through nondisjunction may knock out tumor suppressor gene function. Tumor suppressor gene function may also be lost through an “epigenetic” process that “silences” the gene. Epigenetic influences do not change the DNA sequence (no mutation is required), but change the packaging of DNA and chemically modify it (e.g., methylation) so that the gene is inactivated. This inactivation can be passed on to daughter cells during mitosis.

The Rb Gene The Rb gene codes for a large protein in the cell nucleus (pRb) that has been labeled the “master brake” of the cell cycle (see Chapter 3). It blocks cell division by binding transcription factors (E2F), thereby inhibiting them from transcribing the genes that initiate the cell cycle (Fig. 7.9). The Rb protein can be induced to release the transcription factors when it is sufficiently phosphorylated. Proliferation-promoting signals in the cell increase cyclin-dependent kinase (cdk) enzymes and promote pRb phosphorylation, whereas growth-inhibiting signals prevent phosphorylation. Thus an inactivating mutation of the Rb genes removes one of the major restraints on cell division. Defective pRb is common to a number of different cancers.

the cell from its dependence on growth and survival signals in its environment. This effect usually is accomplished by gain-of-function abnormalities in the proliferation pathways that involve growth factors (mitogens), receptors, cytoplasmic signaling molecules, or nuclear transcription factors.

Tumor Suppressor Genes To become malignant, cells must devise ways to evade the normal inhibitory mechanisms that keep the brakes applied to cell division. It is not enough to simply overstimulate growth-promoting signals. Critical elements of the proliferation-inhibiting pathways are defective in most cancers. The components of the inhibitory machinery are specified by the so-called tumor suppressor genes. Tumor suppressor genes were more difficult to study because they contributed to cancer only when they were not there. The first tumor suppressor gene to be discovered was the Rb gene, so named because of its role in retinoblastoma, a cancer

TABLE 7.5 Viruses Associated With Human Cancers

Virus Associated Cancer Areas of High Incidence

DNA Viruses Papovavirus Family Papillomavirus (many

distinct strains) Warts (benign) Worldwide Carcinoma of the uterine

cervix Worldwide

Hepadnavirus Family Hepatitis-B virus Liver cancer

(hepatocellular carcinoma)

Southeast Asia, tropical Africa

Herpesvirus Family Epstein-Barr virus Burkitt lymphoma (cancer

of B lymphocytes) West Africa, Papua

New Guinea Nasopharyngeal

carcinoma Southern China,

Greenland Human herpesvirus 8 Kaposi sarcoma Central and Southern

Africa

RNA Viruses Retrovirus Family Human T-cell

leukemia virus type I (HTLV-1)

Adult T-cell leukemia/ lymphoma

Japan, West Indies

Human immunodeficiency virus (HIV, the AIDS virus)

Kaposi’s sarcoma (via human herpesvirus 8)

Central and Southern Africa

Flavivirus Family Hepatitis-C virus Liver cancer

(hepatocellular carcinoma)

Worldwide

For all these viruses, the number of people infected is much larger than the number who develop cancer: the viruses must act in conjunction with other factors.

From Alberts B et al, editors: Molecular biology of the cell, ed 6, New York, 2015, Garland Science, p 1130.

TABLE 7.6 Examples of Tumor Suppressor Genes

Gene Cancer

RB Retinoblastoma, sarcoma P53 Li-Fraumeni syndrome, 50% of all tumors DCC Colorectal carcinoma APC Colorectal, stomach, pancreatic BRCA1 Breast, ovarian BRCA2 Breast, ovarian, prostate WT1 Wilms tumor WT2 Rhabdomyosarcoma NF1 Neurofibromatosis type 1, astrocytoma NF2 Neurofibromatosis type 2, meningioma VHL Renal cell carcinoma MEN1 Multiple endocrine neoplasia MTS1 Melanoma, leukemia, sarcomas, several carcinomas SMAD2, SMAD4 Colon, pancreatic PTCH Basal cell carcinoma

128 UNIT II Cellular Function

to survive and continue to replicate (see Fig. 7.10). Genetically unstable cells have a propensity to accumulate more cancer-promoting mutations while they proliferate. The P53 gene is important for therapeutic reasons as well. Chemotherapy- and radiation-induced cell death is mediated in large part by p53. These agents usually do not kill cancer cells directly; rather, they cause enough cellular damage in the target cell to trigger p53-mediated apoptosis. Cancer cells that lack functional p53 may therefore be resistant to some radiation and chemotherapeutic protocols.

BRCA1 and BRCA2 Genes Many tumor suppressor genes have been identified through studies of inherited predisposition to certain types of cancer. The breast cancer genes BRCA1 and BRCA2 are important examples. Women with a family

The P53 Gene The most common tumor suppressor gene defect identified in cancer cells involves P53, so named because of the protein’s molecular mass of 53 kilodaltons (also called TP53). More than half of all types of human tumors lack functional P53. The p53 protein, like pRb, inhibits cell cycling. Unlike pRb, however, normally very little p53 is found in cells, and it accumulates in response to cellular, particularly DNA, damage. P53 is a transcription factor that binds to damaged DNA and regulates hundreds of genes. It stalls cell division, presumably to allow time for DNA repair before DNA replication in the S phase (Fig. 7.10). In the face of excessive damage (or other distress signals), p53 may direct the cell to initiate apoptosis. A defect in p53 function disrupts this important quality control system, allowing genetically damaged and unstable cells

FAMILIAL FORM

PATHOGENESIS OF RETINOBLASTOMA

Somatic cells of parents

Germ cells

Zygote

Somatic cells of child

Retinal cells

Retinoblastoma

SPORADIC FORM

Normal gene

Mutant Rb gene

Mutation

Mutation

Mutation

FIG 7.8 Both DNA copies (alleles) of the Rb tumor suppression gene must be dysfunctional for occurrence of retinoblastoma. Inheriting a defective Rb gene predisposes an individual to the development of cancer because only a single mutational event is required to inactivate pRb function.

CHAPTER 7 Neoplasia 129

Inhibit growth

Phosphorylation of pRb

Activation of cyclins/Cdk

(p16) Release of transcription factors (E2F)

Start S phase

Gene transcription

DNA

Growth factors

(e.g., EGF)

Inhibitory signals

(e.g., TGF-�)

pRb P

P

P

FIG 7.9 The Rb protein functions to bind transcription factors in the nucleus and keep them from participating in the transcription of cell cycle–related genes. pRb is induced to release its hold on the E2F transcription factors when it is sufficiently phosphorylated by cyclin-dependent kinases (cdk). Cyclin-dependent kinases are activated by cyclin proteins that accumulate when growth factors bind to receptors and stimulate growth pathways. Other signals, such as transforming growth factor-β (TGF-β), inhibit the activity of cyclin/cdk through activation of inhibitory proteins such as p16. A loss of pRb function removes the “major brake” on cell division. P, Phosphate group; EGF, epidermal growth factor.

history of breast cancer and an inherited defect in the BRCA1 gene have about a 50% risk of developing breast cancer. The age of onset of inherited breast cancer is earlier than the onset of noninherited (sporadic) forms, and the prevalence of bilateral breast cancer is higher. Inherited forms of breast cancer account for only about 5% to 10% of all cases of breast cancer, but study of the genes involved can provide important insights into breast cancer biology in general.

Defects in numerous other tumor suppressor genes have been identified in certain types of cancers (see Table 7.6), including APC and DCC in colorectal cancer, NF1 and NF2 in neurofibromatosis, and VHL in renal cell cancers. The functions of tumor suppressor genes are varied, but most appear to inhibit proliferation, repair DNA, or induce apoptosis in defective cells. In general, any cellular alteration that promotes proliferation or inhibits cell death can contribute to an increased risk of tumor development.

KEY POINTS • Cancer is thought to develop when proto-oncogenes become inappropriately

activated in a cell or when tumor suppressor genes become inactivated. This change in gene function is usually due to mutations in the cell’s DNA.

• Mutant proto-oncogenes disrupt the intercellular communication pathway that normally regulates cell proliferation. This disruption may occur through abnormal production of growth factors, receptors, cytoplasmic signaling molecules, or nuclear transcription factors.

• Both copies of a tumor suppressor gene usually must be inactivated to eliminate its function. Tumor suppressor genes inhibit cellular proliferation in various ways. The Rb protein serves as a “master brake” on cell proliferation by inhibiting transcription factors. P53 inhibits cell cycling when the cell is damaged to allow time for DNA repair. P53 is also important in initiating apoptosis of damaged or unwanted cells.

MULTISTEP NATURE OF CARCINOGENESIS From the preceding discussion, it might seem that simply activating an oncogene in a normal cell or knocking out a tumor suppressor gene would be sufficient to transform it into a malignant cell. Such has not proved to be the case. Growth regulation of mammalian cells appears to be organized in such a manner that a single aberrant gene is unlikely to induce conversion to full malignancy. Different genes function in distinct ways and may affect only a subset of the changes necessary to achieve full malignancy. For example, introduction of the ras oncogene into normal cells in culture causes them to show anchorage independence, but they are unable to form tumors when inoculated into an animal. Anchorage independence is a typical feature of most transformed cells and means that they are capable of proliferating even if they are not attached to a matrix. Normal cells will not divide and will initiate apoptosis if they do not have a space on the matrix on which to anchor themselves. Similarly, the myc oncogene allows cells to grow indefinitely in culture, but these immortal cells are still unable to induce tumor formation. However, when both the ras and the myc oncogenes are introduced into normal cells, they become fully malignant.

These culture experiments support the clinical observation that carcinogenesis is a multistep phenomenon. The steps of carcinogenesis have been labeled initiation, promotion, and progression (Fig. 7.11).

Initiation Initiating events are thought to be the genetic mutations that inap- propriately activate proto-oncogenes and inactivate tumor suppressor genes. However, the genetic mutations are not evident until the mutant cell proliferates. Proliferation is a requirement for cancer development, and nonproliferating cells are unlikely to cause cancer. It has been suggested that several mutations may be necessary to achieve full malignancy. The development of colorectal cancer is a well-documented example of these sequential changes (Fig. 7.12). Each individual cancer is likely to have its own unique combination of mutations that eventually

130 UNIT II Cellular Function

lead to malignant behavior. Genotyping of tumor cells is an impor- tant development in understanding tumor cells and individualizing therapy.

A number of etiologic agents are considered important initiators of cancer. The term carcinogen is applied to agents and substances capable of inducing cancer. Some carcinogens are complete carcinogens in that they are capable of initiating genetic damage as well as promoting cellular proliferation, whereas many others are only partial carcinogens. Partial carcinogens are often promoters that stimulate growth but are incapable of causing genetic mutations sufficient to initiate cancer by themselves. Examples of known carcinogens are ultraviolet and ionizing radiation, certain viruses, asbestos, and numerous chemicals. Most known chemical carcinogens are encountered through repeated occu- pational exposure (Box 7.1).

Malignant tumor Quiescence/senescenceNormal cells Apoptosis Apoptosis

G1 arrest

Ionizing radiation Carcinogens

Mutagens

Normal cell (p53 normal)

Normal cell (p53 normal)

Cell with mutations or loss of p53

Successful repair Repair fails

No cell cycle arrest

No DNA repair, no senescence

Mutant cells

DNA damage Hypoxia

DNA damage

p53 activated and binds to DNA

DNA damage

p53 activated and binds to DNA

mir-34 transcribed and processed

p53-dependent genes not activated

(apoptosis gene)

Expansion and additional mutations

Transcription dependent and independent effects on targets

GADD45 (DNA repair)

p21 (CDK inhibitor) BAX

Inhibits translation of growth-promoting

genes (i.e, MYC, CDK4)

Inhibits translation of anti-apoptosis

genes (BCL-2)

FIG 7.10 Role of P53 (TP53) in maintaining the integrity of the genome. Damage to DNA in cells with functional P53 stalls the cell cycle so that DNA can be repaired. If repair fails, then the cell undergoes apoptosis to prevent the proliferation of DNA-damaged cells. If the P53 is not functional, genetically unstable cells may be allowed to survive and proliferate.

DNA damage (mutation)

Proliferation (growth promoters)

Development of cancerous phenotype PROGRESSION

PROMOTION

INITIATION

FIG 7.11 Theoretical steps in the development of cancer include initiation, promotion, and progression.

CHAPTER 7 Neoplasia 131

factors. It is not surprising, then, that hormones may act as promoters of certain types of cancer. The relationship between estrogen hormones and breast, ovarian, and uterine cancer is an important example. Epidemiologic studies indicate that the greater the number of menstrual cycles experienced, the higher the risk of these types of cancer developing. Women with early menarche, late first pregnancy, lack of breast-feeding, and late menopause have a greater risk of developing breast, uterine, and ovarian cancer. This enhanced susceptibility is thought to occur in part because of the greater lifetime estrogen exposure. Estrogen is a trophic hormone for these tissues and may therefore be viewed as having promoter effects. Treatment protocols using antiestrogen agents (tamoxifen) indicate that breast cancer risk may be reduced by blocking the effects of estrogen. However, estrogen is not considered to be car- cinogenic and does not cause genetic mutations.

A similar relationship has been identified for prostate cancer and testosterone hormones. In males, testosterone is secreted primarily from the testes under the influence of pituitary gonadotropins. Testosterone is a growth factor for the prostate gland and can act as a promoter of tumor formation in this tissue. This relationship is supported by the fact that therapeutic blocking of testosterone activity in persons with prostate cancer can help shrink the tumor.

Tumor cells frequently produce more than the normal amount of telomerase, an enzyme that allows the cell to repair the ends of the chromosomes (telomeres). Telomere shortening with each cell division normally limits the number of cell cycles in normal cells. Tumor cells must overcome this limit on cell division in order to achieve the immortality required to continue to divide. In the early 1970s it was discovered that normal somatic cells replicate only a finite number of times in culture: fetal cells may replicate approximately 80 times, whereas cells from older individuals divide only 20 or 30 times. Each time a cell divides, it must replicate its DNA, but DNA polymerase is unable to copy the DNA strands all the way to the very tips of the chromosomes (called telomeres). The telomere thus shortens slightly with each cell division until some critical length is reached and cell division stops (see Chapter 4). Stem cells and germ cells produce an enzyme called telomerase that promotes synthesis of the telomere ends and permits these cell types to replicate indefinitely, but normal somatic cells produce little of this enzyme. Most cancer cells begin to synthesize telomerase while they acquire the malignant phenotype, thus rescuing themselves from critical telomere shortening and gaining a mechanism for achieving immortality. In addition, the majority of cancers are deficient in p53 activity, which allows them to escape apoptosis despite gross derange- ments in DNA structure.

Progression Progression is the stage during which the mutant proliferating cells begin to exhibit malignant behavior. The mutations suffered during initiation are not sufficient to cause all the biochemical changes necessary

Promotion Promotion is the stage during which the mutant cell proliferates. The transition from initiation to promotion may involve the activation of another oncogene or the inactivation of a tumor suppressor gene that has kept proliferation in check. Nonmutating factors may also be important in promoting cellular proliferation. Nutritional factors and infection may provide a stimulus for cellular proliferation. As previously described, proliferation is regulated by numerous hormonal growth

FIG 7.12 The development of colorectal cancer illustrates the concept of multistep carcinogenesis. Derange- ment of several genes is likely to occur in most types of cancer. (Redrawn from Alberts B et al, editors: Molecular biology of the cell, ed 6, New York, 2015, Garland Science, p 1126.)

Direct-Acting Carcinogens Alkylating Agents β-Propiolactone Dimethyl sulfate Diepoxybutane Anticancer drugs (cyclophosphamide, chlorambucil, nitrosoureas, and others)

Acylating Agents 1-Acetylimidazole Dimethylcarbamoyl chloride

Procarcinogens That Require Metabolic Activation Polycyclic and Heterocyclic Aromatic Hydrocarbons Benz[a]anthracene Benzo[a]pyrene Dibenz[a,h]anthracene 3-Methylcholanthrene 7,12-Dimethylbenz[a]anthracene

Aromatic Amines, Amides, Azo Dyes • 2-Naphthylamine (β-naphthylamine) • Benzidine • 2-Acetylaminofluorene • Dimethylaminoazobenzene (butter yellow)

Natural Plant and Microbial Products Aflatoxin B1 Griseofulvin Cycasin Safrole Betel nuts

Others Nitrosamine and amides Vinyl chloride, nickel, chromium Insecticides, fungicides Polychlorinated biphenyls

BOX 7.1 Major Chemical Carcinogens

132 UNIT II Cellular Function

METASTASIS Metastasis is the process whereby cancer cells escape their tissue of origin and initiate new colonies of cancer in distant sites. For tumor cells to gain access to the blood or lymphatic circulation, they must first escape the basement membrane of the tissue of origin, move through the extracellular space, and penetrate the basement membrane of the vessel (Fig. 7.14). This process is thought to involve loss of cell-to-cell adhesion and binding to matrix components such as laminin via specific laminin receptors on the tumor cell, followed by release of enzymes such as proteases and collagenases that digest the basement membrane. The cancer cell then squeezes through the rift by ameboid movement. The process is repeated at the vessel basement membrane to access the blood or lymphatic vessel. When the cell reaches the tissue to be colonized, it must again traverse the basement membranes by using similar mechanisms (Fig. 7.15). Once in a new tissue setting, the cancer cell colony must acquire nutrients and a blood supply and cope with an environment that may differ considerably from its origin. In general, less differentiated cancer cells are better able to adapt to foreign tissues and survive.

Patterns of Spread The survival of tumor cells in the circulation is not guaranteed. They may be detected by immune cells and destroyed, or they may undergo apoptosis unless they quickly find a matrix on which to adhere. Fewer than 1 in 10,000 of the cancer cells that enter the circulation survives to form a new tumor at a distant site. Some tumor cell types appear to prefer specific target organs. Sometimes the pattern of metastasis is related to the circulatory flow. For example, metastatic tumors from the colon often seed the liver because they travel within the portal vein. The localization of most metastatic tumors is not so easily explained by blood flow patterns, and some tumor cells appear to “home” to specific targets. This homing tendency is poorly understood but may involve chemotactic signals from the organ to which the tumor cells respond. Cell surface receptors of the integrin and cell adhesion mol- ecule families, which mediate cell-to-matrix and cell-to-cell adhesion, are likely to influence the choice of tissues that cancer cells invade. Dissemination via lymphatics is somewhat more predictable than distribution by blood flow. Generally, the lymph nodes that immedi- ately drain the tissue of cancer origin are colonized first, and then the

for malignant behavior. The proliferating cells are genetically unstable and undergo chance mutations that give them a growth advantage. Clones of mutant cells exhibit a wide variation in phenotype. Phenotype refers to the cell’s traits, such as morphology, metabolism, and biochemi- cal composition. Cells whose phenotype gives them a growth advantage proliferate more readily. With each cycle of proliferation, an opportunity for chance variation arises. In the end, highly evolved tumor cells are generated that differ significantly from their normal ancestors. These cells have developed characteristics such as the presence of laminin receptors, lytic enzymes, and anchorage independence that enable them to behave malignantly.

Cancer cells often have numerous abnormalities of chromosome structure, and the karyotype can be quite bizarre with bits and pieces of chromosomes attached in the wrong places and extra or missing chromosomes. An example of the chromosomes obtained from a typical cancer cell is shown in Fig. 7.13. The color stains are specific for a particular chromosome, and each chromosome pair should be one color.

The fact that conversion from a normal cell type to a malignant cell type requires multiple steps implies many opportunities to intervene in the process. Prevention of the initiating mutation may be difficult inasmuch as carcinogens are ubiquitous; however, therapies to prevent promotion and progression could render the initial mutation harmless. As the biochemical processes governing promotion and progression become clearer, strategies for blocking these stages continue to be developed.

FIG 7.13 Fluorescent images from human colon cancers. (Redrawn from Alberts B et al, editors: Molecular biology of the cell, ed 6, New York, 2015, Garland Science, p 1125. Courtesy of Wael Abdel-Rahman and Paul Edwards.)

KEY POINTS • Full expression of cancer in a host is a multistep process. These steps have

been described as initiation, promotion, and progression. The initiating event is usually from genetic mutations. Promotion refers to the stage in which the mutant cell is induced to proliferate. Progression is the stage during which the mutant proliferating cells acquire properties that allow malignant behavior.

• Malignant cells commonly produce telomerase, an enzyme that repairs the telomeres and may be a key for attaining immortality. The majority also have insufficient p53, which allows the tumor cells to escape apoptosis despite DNA damage.

CHAPTER 7 Neoplasia 133

tumor marker may indicate progression and proliferation of the cancer cells (increased tumor burden). See Table 7.7 for other examples of antigen, hormone, isoenzyme, and immunoglobulin markers used to identify tumor cell types.

Angiogenesis Tumors cannot enlarge more than about 2 mm in diameter unless they grow blood vessels into the tumor mass to provide oxygen and nutrients. Angiogenesis is the process of forming new blood vessels. Most tumors do not induce angiogenesis until late in the stage of cancer development and so remain small and nonvascularized for years. The triggers that spur the cancer to begin angiogenesis are not completely understood. Tumor cells may begin to produce angiogenic factors such as vascular endothelial growth factor (VEGF) in response to hypoxia or other signals. VEGF stimulates proliferation of vascular endothelial cells, which then migrate to the tumor and orchestrate blood vessel development. Meta- static tumors must also initiate angiogenesis in their new locations or they will not survive. Therefore inhibition of angiogenesis is an important therapeutic goal to limit tumor growth and metastasis and continues to be an area of active research.

tumor cells tend to spread contiguously from node to node. Hodgkin disease, a lymphoma, is particularly noted for its orderly spread via the lymphatics.

Because tumor cells exhibit various degrees of differentiation or resemblance to the parent tissue of origin, it may be difficult to determine the metastatic cancer’s tissue of origin. Tumor markers are substances associated with tumor cells that may be helpful in identifying their tissue type. Identification of the tissue of origin has important implica- tions for prognosis and selection of treatment options. Tumor markers rely on the retention of at least some characteristics of the parent tissue type. Some tumor markers are released into the circulation, whereas others must be identified through biopsy of the metastatic tissue. Enzymes and other proteins that are specific to a particular cell type are commonly used as tumor markers. For example, production of thyroglobulin protein is specific for thyroid tumor cells. Melanoma cells express the antigens HMB-45 and S-100, which is helpful in identification as melanocytes. Unfortunately, most tumor markers are not specific for cancer because the normal cells in the tissue of origin also produce them. Tumor markers are most useful as indicators for further diagnostic evaluation and to track the tumor activity. An increasing blood concentration of a specific

Clonal expansion, growth, diversification, angiogenesis Transformed cell

PRIMARY TUMOR

METASTATIC TUMOR

Host lymphocyte

Platelets

Basement membrane

Metastatic subclone

Adhesion to and invasion of basement membrane

Passage through extracellular matrix

Intravasation

Interaction with host lymphoid cells

Tumor cell embolus

Adhesion to basement membrane

Extravasation

Metastatic deposit

Angiogenesis

Growth

FIG 7.14 The metastatic cascade of events.

134 UNIT II Cellular Function

location and pattern of spread of a tumor within the host. Factors such as tumor size, extent of local growth, lymph node and organ involvement, and presence of distant metastases are considered. Several staging systems exist; however, the international TNM (tumor, node, metastasis) system is used extensively as a general framework for staging tumors. Particular staging criteria vary with tumors in different organ systems. An example of staging criteria for breast cancer is shown in Table 7.8.

In the past, tumor staging was based primarily on results of radiogra- phy and exploratory surgery. The availability of computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and other highly sophisticated imaging techniques has revolu- tionized cancer detection. These imaging modalities allow noninvasive

Grading and Staging of Tumors Grading and staging of tumors are done to predict the clinical behavior of a malignant tumor and to guide therapy. Grading refers to the histologic characterization of tumor cells and is basically a determination of the degree of anaplasia. Most grading systems classify tumors into three or four classes of increasing degrees of malignancy. A greater degree of anaplasia indicates a greater malignant potential. The correlation between the grade of the tumor and its biological behavior is not perfect. Some low-grade tumors have proved to be quite malignant.

The choice of treatment modality is usually influenced more by the stage of the tumor than by its histologic grade. Staging describes the

LamininType IV collagen

Basement membrane

Cadherins

A. LOOSENING OF INTERCELLULAR JUNCTIONS

Laminin receptor

C. ATTACHMENT

Type IV collagen cleavage

Type IV collagenase

Plasminogen activator

B. DEGRADATION

D. MIGRATION

Fibronectin receptor

Autocrine motility factor

Fibronectin

Type IV collagen Laminin

FIG 7.15 Mechanisms of tumor invasion allow tumor cells to escape the site of origin, penetrate the basement membrane, and travel to distant sites. A, Tumor cells decrease cell-to-cell attachments via cadherins that allow detachment and migration toward the basement membrane. B, Enzymes that degrade proteins are released into the area to form a rift. C, The tumor cell migrates away from the site of origin using laminin and fibronectin receptors to pull through the tissue. D, Finally the cell moves through a rift in the matrix.

CHAPTER 7 Neoplasia 135

KEY POINTS • Malignant cells produce specialized enzymes and receptors to enable them

to escape their tissue of origin and metastasize. • The spread of tumors generally occurs by way of the bloodstream or lymphat-

ics. Tumor cells often lodge in the capillary beds of the organs that drain them, such as liver and lung. Some tumors appear to “home” to certain tissues.

• Grading and staging are done to predict tumor behavior and guide therapy. Grading is the histologic characterization of tumor cells, whereas staging describes the location and pattern of tumor spread within the host.

• The TNM (tumor, node, metastasis) staging system is used to describe the tumor size, lymph nodes affected, and degree of metastasis.

TABLE 7.7 Selected Tumor Markers

Hormones Human chorionic gonadotropin Trophoblastic tumors,

nonseminomatous testicular tumors Calcitonin Medullary carcinoma of thyroid Catecholamine and metabolites Pheochromocytoma and related tumors Ectopic hormones Paraneoplastic syndromes

Oncofetal Antigens α-Fetoprotein Liver cell cancer, nonseminomatous

germ cell tumors of testis Carcinoembryonic antigen Carcinomas of colon, pancreas, lung,

stomach, and heart

Isoenzymes Prostatic acid phosphatase Prostate cancer Neuron-specific enolase Small cell cancer of lung,

neuroblastoma

Specific Proteins Immunoglobulins Multiple myeloma and other

gammopathies Prostate-specific antigen and

prostate-specific membrane antigen

Prostate cancer

Mucins and Other Glycoproteins CA-125 Ovarian cancer CA-19–9 Colon cancer, pancreatic cancer CA-15–3 Breast cancer

Cell-Free DNA Markers p53, APC, and RAS mutants in

stool and serum Colon cancer

p53 and RAS mutants in stool and serum

Pancreatic cancer

p53 and RAS mutants in sputum and serum

Lung cancer

p53 mutants in urine Bladder cancer

TABLE 7.8 American Joint Committee on Cancer and Union Contre Le Cancer Staging*

Stage T: Primary Cancer N: Lymph Nodes M: Distant Metastasis 10-Year Survival (%)

0 DCIS or LCIS No metastases Absent 92 I Invasive carcinoma ≥2 cm No metastases or only

micrometastases Absent 87

II Invasive carcinoma >2 cm 1–3 positive nodes Absent 65 Invasive carcinoma >5 cm but ≤5 cm 0–3 positive nodes Absent

III Invasive carcinoma >5 cm Negative or positive nodes Absent 40 Any size invasive carcinoma ≥4 positive nodes Absent Invasive carcinoma with skin or chest wall

involvement or inflammatory carcinoma Negative or positive nodes Absent

IV Any size invasive carcinoma Negative or positive lymph nodes Present 5

DCIS, ductal carcinoma in situ; LCIS, lobular carcinoma in situ; M, metastasis; N, nodes; T, tumor. *The groups listed in the table are based on the characteristics of the primary carcinoma and the axillary lymph nodes. For rare women with involved internal mammary lymph nodes or supraclavicular lymph nodes, there are additional staging criteria. From Kumar V, Abbas A, Aster JC: Neoplasia. In Kumar V, Abbas A, Aster JC, editors: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p 1068.

exploration of the tissues of the entire body. The computer-generated images can then be scrutinized for any signs of abnormality that might signal the presence of hidden tumors. CT and MRI rely primarily on detection of differences in tissue density and are therefore not totally specific for tumors. They can, however, guide the selection of sites for exploration and biopsy and potentially reduce unnecessary surgery. PET is a promising staging technology because it facilitates cancer detection based on molecular and biochemical processes within the tumor tissues (Fig. 7.16). PET may be used in certain clinical situations in which CT has known limitations, such as differentiation of benign from malignant lymph nodes or other lesions, differentiation of residual tumor from scar tissue, or detection of unsuspected distant metastases.

Antibodies can also be used to locate cancer cells in the body. Antibodies can be raised against specific antigens present on the surface of tumor cells. The antibodies are also bound to a tracer (e.g., a radioac- tive isotope such as iodine-125), which can be detected by imaging. Because methods for identifying tumor antigens and raising specific antibodies have improved, this technology provides the potential for finding very small numbers of tumor cells hidden in the body.

The results of the staging procedure will determine which of the mainstays of cancer treatment—surgery, radiation therapy, or chemotherapy—may be used, singly or in combination, to destroy the cancer cells. Localized tumors may be managed with surgery and radiation therapy, whereas evidence of metastasis generally necessitates the addition of chemotherapy.

136 UNIT II Cellular Function

the cancer cells or immune cells. Cancer patients may have aversions to specific foods and may feel full after only a few bites. Nausea and vomiting are common complications of cancer therapy and contribute to decreased nutrient intake. Despite the minimal nutrient intake, body metabolism remains high. Production of tumor necrosis factor and other immune cytokines is thought to be important in producing the hypermetabolic state. Nutrients are mobilized from fat and protein stores in the body and consumed by the hypermetabolic cells (see Chapter 42). Some patients may require nutritional supplementation by enteral or parenteral routes.

Individuals with cancer often demonstrate deficits in immune system competence. Cancer cells secrete substances that suppress the immune system. Individuals with cancer may have reduced populations of T and B cells and may respond poorly to injected antigens. The mechanisms by which cancer cells depress immune responses are varied, but the prognosis for cancer recovery is poorer when the immune system is depressed. Immune cells, including cytotoxic T cells and natural killer

Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious change in wart or mole Nagging cough or hoarseness

BOX 7.2 Cancer’s Seven Warning Signs

Continued, unexplained weight loss Headaches with vomiting in the morning Increased swelling or persistent pain in bones or joints Lump or mass in abdomen, neck, or elsewhere Development of whitish appearance in pupil of the eye Recurrent fevers not caused by infections Excessive bleeding or bruising Noticeable paleness or prolonged tiredness

BOX 7.3 Cancer’s Warning Signs in Children

FIG 7.17 General emaciated appearance in cancer cachexia. (Courtesy Dr. P. Marazzi/Science Photo Library.)

FIG 7.16 PET scan that detects uptake of radioactively labeled glucose is overlaid onto a CT scan background image. The yellow spots in the abdomen and mediastinum are indicative of multiple metastases of non-Hodgkin lymphoma. (From Alberts B et al, editors: Molecular biology of the cell, ed 6, New York, 2015, Garland Science, p 1092. Courtesy Dr. Sanjiv Sam Gambhir.)

EFFECTS OF CANCER ON THE BODY The effects of cancer on the host vary widely, depending on the location of the tumor and the extent of metastasis. Early-stage cancer may be asymptomatic. As the tumor increases in size and spreads through the body, a number of symptoms typically become apparent, including pain, cachexia, immune suppression, and infection. Once treatment has begun, patients may also suffer hair loss and sloughing of mucosal membranes. The ACS has published the seven warning signs of cancer as a way of encouraging the public to seek early evaluation of potential cancers (Box 7.2). The presentation of cancer in children differs from that in adults, and special warning signs have been identified for the pediatric population (Box 7.3).

Pain is a common and feared complication of the disease process. Pain may be due to invasion of metastatic cells into organs or bone and subsequent activation of pain and pressure receptors in these tissues. Tissue destruction and inflammation may contribute to cancer pain. Cancer treatment may contribute to overall pain because of procedures requiring biopsy and intravenous drug administration. Pain can usually be controlled through the use of analgesics. The use of patient-controlled analgesia has been effective in reducing patient fears of inadequate therapy for pain (see Chapter 47).

Cachexia refers to an overall weight loss and generalized weakness (Fig. 7.17). Many factors contribute to cancer cachexia, including loss of appetite (anorexia) and increased metabolic rate. Anorexia accom- panies many disease processes and may result from toxins released by

CHAPTER 7 Neoplasia 137

KEY POINTS • Regardless of the type of malignancy, affected individuals exhibit characteristic

signs and symptoms, including pain, cachexia, bone marrow suppression, and infection.

• Bone marrow suppression is manifested as anemia, leukopenia, and thrombocytopenia.

• Immunosuppression with consequent infection is a primary cause of cancer- associated death.

If left untreated, cancer has the potential to kill the host. The cause of death is multifactorial. Infection, hemorrhage, and organ failure are the primary causes of cancer death. The failure of cancer-ridden organs such as the liver, kidney, brain, and lung results in the loss of life- sustaining functions. Treatment for cancer can also be detrimental to the host by contributing to immunosuppression and platelet deficiencies. The cumulative effects of one or more of these factors may lead to death.

(NK) cells, are needed to actively detect and destroy cancer cells (see Chapter 9).

Bone marrow suppression contributes to the anemia, leukopenia, and thrombocytopenia that often accompany cancer. Bone marrow suppression may be due to invasion and destruction of blood-forming cells in the bone marrow, poor nutrition, and chemotherapeutic drugs. Anemia refers to a deficiency in circulating red blood cells. In addition to decreased production of blood cell precursors in the bone marrow, anemia may result from chronic or acute bleeding. The signs and symptoms of anemia, such as fatigue, increased heart rate, and increased respiratory rate, are related to a decrease in oxygen-carrying capacity.

Leukopenia refers to a decrease in circulating white blood cells (leukocytes). Malignant invasion of the bone marrow is a primary cause of leukopenia, with malnutrition and chemotherapy being contributing factors. A deficiency in white blood cells reduces the patient’s ability to fight infection, which is a major cause of morbidity and mortality in cancer patients. Often the offending organism is opportunistic; it is unable to infect an immunocompetent host and becomes virulent only when a person is immunocompromised. Infections are quite difficult to manage because the host is unable to mount an effective immune response. Infections are also difficult to prevent because the majority of the infecting organisms are from the patient’s own endogenous flora (e.g., skin, gastrointestinal tract). The development of severe leukopenia or infection during treatment may necessitate changes in the chemo- therapeutic regimen to allow bone marrow recovery.

Thrombocytopenia is a deficiency in the number of circulating platelets, which are important mediators of blood clotting. Platelet deficiencies predispose to life-threatening hemorrhage. A platelet count of less than 20,000/mm3 has been associated with spontaneous hemorrhage.

Anemia, leukopenia, and thrombocytopenia may be managed by administration of blood products containing red blood cells, white blood cells, and platelets, respectively. In fact, blood replacement therapy is used more often in cancer patients than in patients with any other medical condition. When chemotherapy is terminated, stem cells in the bone marrow generally recover and the production of blood cells resumes. In some cases, the production of red and white blood cells can be enhanced by treating the patient with specific growth factors, such as erythropoietin (Epogen) or granulocyte-stimulating factors (Neupogen).

Hair loss and the sloughing of mucosal membranes are complications of radiation therapy and chemotherapy. Treatment is designed to kill the rapidly proliferating cancer cells, but normal cells with high growth rates such as mucosal epithelia and hair follicle cells are also damaged. Damaged mucosa is a primary source of cancer pain and anorexia, and may provide a portal for the invasion of organisms from the skin or gastrointestinal tract.

Paraneoplastic syndromes are symptom complexes that cannot be explained by obvious tumor properties and occur in 10% to 15% of patients with cancer. Many of the syndromes are associated with excessive production of hormones or cytokines by the tumor. Common para- neoplastic syndromes include (1) hypercalcemia, (2) Cushing syndrome secondary to excess adrenocorticotropic hormone (ACTH) secretion, and (3) hyponatremia and water overload secondary to excess antidiuretic hormone (syndrome of inappropriate ADH) secretion. Small cell carcinoma of the lung is commonly the culprit for excess ACTH and ADH syndromes. Hypercalcemia (elevated concentration of serum calcium) is a paraneoplastic syndrome associated with abnormal produc- tion of parathyroid hormone–related protein by the tumor cells. Unexplained hypercalcemia is regarded as evidence of cancer until proven otherwise. Hypercalcemia may be a consequence of metastatic bone cancer, and in this case it would be an expected finding rather than a paraneoplastic syndrome.

CANCER THERAPY The overall 5-year survival rate for patients with cancer is approximately 68%, with some types of cancer having much higher or lower rates. Early detection of cancer, while it remains localized in the tissue of origin, is associated with the best prognosis for cure. Cure implies eradication of all cancer cells in the body and is different from the 5-year survival rate. Patients with metastatic invasion of regional lymph nodes still have a good opportunity for cure with appropriate therapy. Widespread invasion of multiple tissues and organs is associated with a poor prognosis, and therapy may be aimed at remission or palliation of symptoms rather than cure. The mainstays of cancer therapy are surgery, radiation therapy, and drug therapy. In some hormone-sensitive tumors (breast, prostate), hormonal-blocking drugs may be used.

Immunotherapy and targeted molecular therapies have begun to emerge as important treatments for specific cancers. Traditional forms of treatment are not selective for cancer cells and result in unavoidable damage to normal tissue. The immune system, on the other hand, is noted for its ability to make subtle distinctions between normal and abnormal or foreign cells. Recognition of tumor cells as different from their normal counterparts is the basis of tumor immunology. Recognition depends on the expression of abnormal molecules or antigens on the cancer cell surface. Unfortunately, most tumor-associated antigens are also expressed to some degree on normal cells, which makes it difficult to develop strategies to target cancer cells selectively. However, genetic analysis of a tumor sometimes can give clues to potential and unique therapeutic targets. Ultimately, the choice of treatment depends largely on the results of the staging procedure. A greater degree of metastasis generally requires a more aggressive therapeutic approach.

Surgery The majority of patients with solid tumors are treated surgically, which can be curative in some localized cancers. The main benefit of surgery is removal of a tumor with minimal damage to other body cells. The surgeon generally removes a margin of normal-appearing tissue around the resected tumor to ensure complete tumor removal. Lymph nodes are subjected to biopsy and also removed if evidence of metastasis is present. Surgical resection of some tumors can be tricky if vital structures such as neurons or blood vessels are involved.

Surgery involves risks related to the effects of anesthesia, infection, and blood loss. The surgical procedure may be disfiguring or may result in loss of function. Surgical resection as the sole treatment for solid

138 UNIT II Cellular Function

particularly those of the bone marrow, intestinal epithelia, and hair follicles, are most affected. Bone marrow depression is a most serious side effect inasmuch as it predisposes the patient to anemia, bleeding, and infection.

New approaches to cancer drug therapy have emerged that indirectly inhibit tumors rather than seeking to eradicate tumor cells directly. One approach is to interrupt the tumor’s blood supply. To proliferate, solid tumors must be supplied by a progressively expanding network of capillaries. The development of new capillaries, called angiogenesis, is accomplished by migration and growth of endothelial cells. Antian- giogenic drugs block the development of new capillaries.

Immunotherapy Harnessing the power of the immune system to fight cancer is a par- ticularly appealing idea because of the potential for specificity. Current modes of immunomodulation primarily involve the use of interferons, interleukins, and monoclonal antibodies. These therapies are generally used as adjuncts to surgery, irradiation, and chemotherapy.

Interferons are glycoproteins produced by immune cells in response to viral infection. Interferons inhibit cell proliferation and are stimulatory to NK cells, T cells, and macrophages. Interferon-α has been used successfully to treat hairy cell leukemia (a rare B-cell malignancy), chronic myelogenous leukemia, and multiple myeloma. Interferon therapy produces symptoms similar to those of a viral infection: fever, chills, and muscle aches.

Interleukins are peptides produced and secreted by white blood cells. They are also called lymphokines or cytokines. Interleukin-2 (IL-2) is an important cytokine secreted by activated T helper cells. It stimulates the proliferation of T cells, NK cells, and macrophages. IL-2 can be used to stimulate the growth of these immune cells in culture. Immune cells taken from a patient’s blood can be grown in culture in the presence of IL-2. Then the greatly expanded number of immune cells can be given back to the patient, along with intravenous infusions of IL-2. Such treatment has been associated with regression of some tumors (melanoma, renal cell carcinoma). However, because IL-2 toxicity is high and many individuals have severe allergic reactions, the benefit of therapy must be weighed against the risks for each individual situation.

The use of monoclonal antibodies (antibodies having identical structure) in cancer therapy is currently the subject of intense investiga- tion. Monoclonal antibodies specifically bind with target antigens and can therefore be used in several ways as treatment for cancer. Antibodies can be used to deliver a cytotoxic drug preferentially to the cancer cell and thus minimize drug interactions with normal cells. Similarly, antibodies can be used to direct other cytotoxic cells, such as NK and T cells, to tumor cells lurking in the body. Antibodies can be attached to a radioactive label and injected into a patient to screen for recurrence of tumor growth. Antibodies can also be directed against cells that support tumor growth.

Monoclonal antibodies have been developed for management of several cancers. For example, nearly 25% of breast cancers have over- expression of the HER2 receptor on the surface of malignant cells. The monoclonal antibody trastuzumab specifically binds to this HER2 protein and helps immune cells find and kill the tumor cells. A summary of selected monoclonal antibody agents and their main tumor protein targets is shown in Fig. 7.18.

Gene and Molecular Therapy Because cancer is fundamentally a disorder of gene function, the use of gene therapy to alter the malignant behavior of cells may have high therapeutic potential. As specific gene derangements are identified for particular tumors, gene therapy may be used to suppress overactive

tumors is curative in a minority of patients because most patients already have undetectable metastases at the time of diagnosis. Therefore surgical resection is commonly accompanied by radiation therapy or chemo- therapy. Even one remaining cancer cell could be sufficient to reinitiate tumor formation.

Radiation Therapy Ionizing radiation is used for two principal reasons: to kill tumor cells that are not resectable because of location in a vital or inaccessible area and to kill tumor cells that may have escaped the surgeon’s scalpel and remain undetected in the local area. Radiation kills cells by damaging their nuclear DNA. Cells that are rapidly cycling are more susceptible to radiation death because there is little time for DNA repair. Radiation doses generally do not kill cells directly, but cause enough cell damage to initiate apoptosis. The P53 tumor suppressor gene is an important mediator of this response. Many tumors have mutant P53 and may be less susceptible to radiation-induced cell death.

It is difficult to kill all the cells of a large tumor by irradiation because they are heterogeneous—they are in different phases of mitosis and are cycling at different rates. A single radiation dose large enough to kill all the tumor cells would be sufficient to kill the normal cells as well. Radiation is often administered in smaller doses over several treatments and is most effective at eradicating small groups of tumor cells. It is often used in combination with surgery. Radiation is also useful for palliative reductions in tumor size. Pain from bone and brain tumors may be effectively managed with radiation therapy that shrinks the tumor. Tumors with bleeding surfaces may be coagulated with radiation to decrease blood loss.

A certain degree of destruction of normal cells in the irradiated field is expected with radiation therapy. Radiation is best used when tumor cells are regionally located. Total-body irradiation to kill tumor cells in disseminated locations is not recommended because of the likelihood of life-threatening tissue damage, although it may be used in preparation for bone marrow or peripheral stem cell transplantation.

Drug Therapy Chemotherapy generally refers to the systemic administration of anticancer chemicals as treatment for cancers that are known or suspected to be disseminated in the body. Unlike surgery or radiation therapy, which is locally or regionally applied, parenterally administered che- motherapeutic drugs can find their cancer cell targets in areas throughout the entire body.

Most chemotherapeutic agents are cytotoxic because they interfere with some aspect of cell division. The more rapidly dividing cells are more susceptible to the killing effects of chemotherapeutic agents. In a large tumor mass, the rates of cell division are highly diverse, with many slowly dividing cells. At any one time, only a portion of the tumor cells are in a cell cycle stage that is susceptible to chemotherapy. Several courses of chemotherapy are generally necessary to ensure that all tumor cells have been killed. It is difficult to kill slowly cycling tumor cells without also killing normal cells that are cycling at approximately the same rate. Small tumors are easier to eradicate because rates of cell division are generally faster. To prevent relapse, the “stem” cells that develop into clones of malignant cells must be destroyed. Unfortunately, stem cells may not divide as rapidly as other cells. Resection or irradiation to reduce tumor size may prompt the stem cells to divide, thus making them more susceptible to chemotherapy. Tumor cells with mutations of the P53 gene may be resistant to chemotherapeutic agents that work by damaging DNA, so drugs that act by interfering with the cancer cell cycle in other ways may be more effective.

Chemotherapeutic agents are not selective for tumor cells, and a certain amount of normal cell death also occurs. Rapidly dividing cells,

CHAPTER 7 Neoplasia 139

Rituximab 90Y-lbritumomab tiuxetan

131I-Tositumomab

Gemtuzumab ozogamicin

Alemtuzumab

Imatinib Dasatinib

Trastuzumab Lapatinib

Cetuximab Panitumumab Erlotinib Gefitinib

Sorafenib Sunitinib

Bevacizumab

BCR-A BL

Hematologic malignancies

Solid tumors

VEGF

CD5 2

VEGFR

CD 33

EGFR

CD 20

HER2/neu

FIG 7.18 Cancer cells express abnormal antigens (tumor-associated antigens) on their cell surface that can activate immune cells or be used as targets for monoclonal antibodies. Numerous medications are now available that use monoclonal antibodies to target cellular proteins relevant to several different types of cancer.

Molecular therapies that target cytoplasmic signaling pathways have also been developed. For example, in chronic myelogenous leukemia a chromosomal rearrangement results in the abnormal production of an enzyme, BCR/ABL. This enzyme stimulates cell proliferation and contributes to the overproduction of leukemic cells. An agent that specifically inhibits this enzyme (imatinib) has dramatically improved the management of this disease. Other drugs that specifically target abnormal tumor characteristics continue to be developed.

Stem Cell Transplantation Transplantation of hematologic stem cells is used to manage life- threatening disorders in which the patient’s bone marrow is incapable of manufacturing white blood cells, red blood cells, or platelets. Most often, nonfunctional marrow is a consequence of the high-dose che- motherapy and radiation used to manage hematologic malignancies such as leukemia and lymphoma. Stem cell transplantation also has been applied to other malignancies (e.g., breast cancer) and to non- malignant disorders (e.g., aplastic anemia, sickle cell anemia, and thalassemia). Stem cells can be harvested from aspirates of bone marrow or from the donor’s peripheral bloodstream. Bone marrow is rich in stem cells, but the peripheral blood is poor. The stem cell donor can be a tissue-matched individual (allogeneic), an identical twin (syngeneic), or the patient in question (autologous). A closer match between donor and recipient is associated with a better outcome.

oncogenes or replenish missing tumor suppressor function. Current uses of gene therapy for cancer include genetic alteration of tumor cells to make them more susceptible to cytotoxic agents or immune recogni- tion, and genetic alteration of immune cells to make them more efficient killers of tumor cells.

Tumor cells can also be made more recognizable to immune cells by insertion of genes that cause the tumor cells to express “foreign” proteins on their cell surface. This type of gene therapy has shown some benefit in melanoma and renal carcinoma. Replacement of genes for P53 is an attractive therapy because tumor cells would be more susceptible to apoptosis. Gene replacement of other tumor suppressors such as pRb or APC in those tumors that are deficient could help inhibit tumor proliferation.

Gene therapy can be directed at cells other than tumor cells to enhance the body’s cancer defenses. One such approach involves harvest- ing immune cells from the cancer patient, inserting IL-2 genes, and then returning the genetically enhanced immune cells to the patient. The enhanced immune cells attack the tumor cells more vigorously than normal immune cells do and have been shown to persist in the body for 6 months or longer.

At present, gene therapy is limited by difficulty in delivering the new genes to the target cells. As methods improve, gene therapy will become an increasingly important part of cancer prevention and management.

140 UNIT II Cellular Function

Before infusion of donor stem cells, the patient’s own immune cells must be suppressed to prevent transplant rejection. It is also necessary to eliminate any residual malignant cells from the body to avoid relapse of the cancer. Both of these objectives can be accomplished through high-dose chemotherapy and total-body irradiation regimens, which leave the patient susceptible to severe anemia, infection, and bleeding. The therapeutic goal of stem cell transplantation is to restore immune and hematopoietic function. It may take weeks to months for the infused stem cells to reestablish themselves and begin to proliferate in their new host. During this time, the transplant recipient requires intensive monitoring and management of complications.

The success of stem cell transplantation depends on a number of factors, including the age of the patient, closeness of tissue matching, stage of cancer, and general health status of the patient before transplanta- tion. Transplantation is an expensive undertaking, but may significantly improve disease survival rates in some malignancies.

KEY POINTS • Early detection of cancer while it remains localized is associated with the

best prognosis for cure. The overall 5-year survival rate for patients with cancer is about 68%.

• The mainstays of cancer therapy are surgery, radiation therapy, and che- motherapy. Surgery and radiation therapy are effective for cancers that are localized. Chemotherapy is usually the treatment of choice for cancers known or suspected to be disseminated in the body.

• Cells that divide rapidly are the most susceptible to damage from radiation therapy or chemotherapy. However, in addition to cancer cells, rapidly dividing normal cells may be killed. Cells of the bone marrow, hair follicles, and gastrointestinal mucosa are particularly susceptible.

• Immunotherapy has the potential to specifically target cancer cells. Numerous monoclonal antibodies have been developed to boost the immune system’s ability to locate and destroy cancer cells.

• Gene and molecular therapy may be used to alter cancer cells to suppress oncogenes, enhance tumor suppressor genes, make tumor cells more susceptible to cytotoxic agents, or interfere with the function of cancer gene products.

• Transplantation of hematopoietic stem cells is an important adjunct to cancer therapy that provides a method to restore bone marrow function after high-dose irradiation or chemotherapy.

Neoplasia is abnormal cell proliferation of a benign or malignant nature. Benign tumors resemble their parent cells and are strictly local, whereas malignant tumors are anaplastic, invade local tissues, and may spread to distant sites (metastasize). The most important consideration for cancer management is the degree of cancer spread in the body, which can be determined by staging procedures. Cancer is managed by surgical removal, radiation therapy, chemotherapy, and immunotherapy.

Cancer cells have complex relationships with the host. The host immune system is capable of—but not always successful in—recognizing and killing cancer cells. Cancer cells exert immunosuppressive effects on the host and eventually cause pain, cachexia, and bone marrow suppression. If untreated, cancer has the potential to kill the host by multifactorial processes, including infection, hemorrhage, and organ failure. If treated, cancer has an overall 5-year survival rate of approxi- mately 68%.

Cancer is an outcome of genetic predispositions and environmental carcinogens. Tobacco use and improper nutrition are the two most

studied carcinogenic lifestyle factors. Tobacco is clearly carcinogenic through its ability to cause genetic damage and to promote the growth of mutant cells.

Cancer is thought to develop when proto-oncogenes become inap- propriately overactivated in the cell or tumor suppressor genes become inactivated. This change in activation is usually due to a mutational event in the cell’s DNA. Oncogenes are believed to disrupt intercellular communication, which normally exerts growth-controlling effects on the cell. This disruption is accomplished primarily through the production of abnormal growth factors, growth factor receptors, cytoplasmic signaling molecules, or nuclear transcription factors that allow the cancer cell to manufacture its own growth-promoting signals. The tumor suppressor genes Rb and P53 are important inhibitors of cell replication. The Rb protein binds and sequesters transcription factors, whereas p53 monitors the integrity of cellular DNA and may initiate apoptosis (cell suicide) when significant cell damage occurs. Loss of tumor suppressor gene function occurs in most cancers.

S U M M A R Y

RESOURCES Cancer Epidemiology Albanes D, et al: Effects of alpha-tocopherol beta-carotene cancer prevention

study. Am J Clin Nutr 61:S1427–S1430, 1995. Alberts B, et al: Cancer. In Alberts B, et al, editors: Molecular biology of the

cell, ed 6, New York, 2015, Garland Science, pp 1091–1144. American Cancer Society: Cancer facts and figures—2015, Atlanta, GA, 2015,

Author. American Cancer Society: Cancer prevention and early detection facts & figures

2015-2016, Atlanta, GA, 2015, Author. Goodman M, Bostick RM, Kucuk O, Jones DP: Clinical trials of antioxidants

as cancer prevention agents: past, present, and future. Free Radic Biol Med 51(5):1068–1084, 2011.

Kumar V, Abbas A, Aster JC: Neoplasia. In Kumar V, Abbas A, Aster JC, editors: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, pp 265–340.

Omenn GS, et al: Risk factors for lung cancer and for intervention effects in CARET, the beta-carotene and retinol efficacy trial. J Natl Cancer Inst 88(21):1550–1559, 1996.

Cancer Biology Cuzick J, DeCensi A, Arun B, et al: Preventive therapy for breast cancer: a

consensus statement. Lancet Oncol 12(5):496–503, 2011. Dulbecco R: Cell transformation by viruses. Science 166:962–968, 1969. Hayflick L: The biology of human aging. Adv Pathobiol 7(2):80–99, 1980. McCann J, Ames BN: Detection of carcinogens as mutagens in the

Salmonella/microsome test: assay for 300 chemicals: discussion. Proc Natl Acad Sci USA 73:950–955, 1976.

Paradiso A, Formenti S: Hereditary breast cancer: clinical features and risk reduction strategies. Ann Oncol 22(Suppl 1):I31–I36, 2011.

Weinberg RA: Tumor suppressor genes. Science 254:1138–1146, 1991.

141

UNIT III Defense

Infectious Processes Brent A. Banasik

8

K E Y Q U E S T I O N S • How does the human microbiome regulate the environment of

mucosal surfaces and protect from pathogens? • What are opportunistic infections, and when do they develop? • What conditions compromise host defenses against

microorganisms? • What factors influence the virulence of infectious agents?

• How do environmental factors such as climate, poverty, global travel, and bioterrorism influence the risk of infectious diseases?

• What are the important microorganisms that affect humans, including bacteria, viruses, fungi, and parasites, and how do differences in structure and life cycle affect infectious processes?

C H A P T E R O U T L I N E Host–Microbe Relationship, 142

The Human Microbiome, 142

Host Characteristics, 142

Physical and Mechanical Barriers, 142 Impaired Immune Function, 143

Pathogen Characteristics, 144

Adherence and Invasion, 144 Bacterial Endotoxin, 144 Bacterial Exotoxins and Enzymes, 145 Evasion of Immune Cells, 145 Endospore Formation, 145 Antimicrobial Resistance, 145

Transmission of Infection, 147 Routes of Transmission, 148

Emerging Infectious Diseases, 148

Weapons of Bioterrorism, 149

Types of Pathogenic Organisms, 149 Bacteria, 149

Viruses, 150

Fungi, 151

Parasites, 152

http://evolve.elsevier.com/Banasik/pathophysiology/

Infectious diseases can be caused by a variety of pathogenic microorgan- isms when they gain access to the body through skin and mucous membranes. The importance of maintaining the integrity of these surface barriers and protecting them from contamination has been an important principle of infection control since the days of Florence Nightingale. Only recently have researchers come to realize that the human body is teeming with a staggering number of diverse microorganisms that outnumber the cells in the human body by more than tenfold! This so-called microbiome is important for protection against transient pathogens, but is also a ready source of opportunistic organisms should the immune system be altered.

A variety of pathogens inhabit different environments such as hospitals, the food supply, water, animals, and humans. Globaliza- tion of the world’s population and extensive travel by air have had major implications for the worldwide spread of infectious agents, sometimes even before the infected individual becomes symptomatic or identifiable.

Medications that inhibit the immune response in populations such as transplant or cancer patients and the increasing use of immu- nomodulators for treatment of diseases like rheumatoid arthritis increase the likelihood of infections. Excessive use of antibiotics in humans and domesticated animals has contributed to the emergence

• Review Questions and Answers • Glossary (with audio pronunciations for selected terms) • Animations

• Case Studies • Key Points Review

142 UNIT III Defense

affected by diet, hormones, medications, and metabolism. Each individual is therefore likely to have a different microbiome depending on where they live, what they eat and drink, what medications they take, their genetics, and with whom they come into contact. Understanding the microbiome ecosystem and finding ways to modulate it to advantage is an active area of research. Not all commensal organisms are bacteria, although the most research has been on the microbiome of the gastrointestinal tract, which contains numerous bacterial species. The majority of gut microbiota are known phyla, such as Actinobacteria, Firmicutes, and Bacteroidetes; however, about 25% of an individual’s diverse niches throughout the body are unknown. Recent research suggests that the average individual houses 1000 to 1150 different bacterial species and contains more than 100-fold as many genes than the human host’s genome. Bacteria have been detected in fetal umbilical cord, meconium, and amniotic fluid, suggesting that the complex colonization of commensal bacteria develops prebirth and not just during the birthing process. Commensal microbiota development in infants after delivery is quite rapid and dependent on many sources, including introduction of maternal microbiota via feces from the gastrointestinal tract through vaginal delivery; microflora from cesarean section and breast milk; and environmental inoculum from the air, hospital staff, and eventually from consuming solid foods.

Often recognized as a gram-negative pathogen, Escherichia coli was determined to be among the first commensal microbes that inhabit the infant gut and contribute to broad-spectrum immunity and reduced infections. The harmony of human microbiota can be drastically affected by probiotic or antibiotic usage. Traditionally, probiotics have been administered as gastrointestinal remedies, but recent research has linked them to prevention and treatment of many diseases that include immune and atopic disease, obesity, and even diabetes. It is commonly accepted that antibiotics disrupt gut microflora and provide a niche for enteric pathogens to take root in their absence. In addition, recent research suggests that indigenous commensal bacteria unexpectedly translocated across the gut epithelium in the presence of antibiotics induced an inflammatory response and epithelial injury that led to pathogen growth.

The development of infection in a host depends on complex relation- ships among environmental exposure, host susceptibility, and microbial virulence (Fig. 8.1).

Host Characteristics The host’s defense system is responsible for identifying, repelling, and eliminating pathogens while minimizing injury to its own tissues. Innate cells that recognize a wide variety of pathogens on first exposure accomplish initial responses to pathogens. Innate responses are generally most efficient against bacterial and parasitic infections, but not effective against viral antigens on first exposure. The specific cells of the immune system—B cells and T cells—are able to respond to viral antigens as well as other foreign invaders, but generally take days to weeks to become effective. With subsequent exposure these cells are able to mount such a robust response that the host may not become ill. Innate and specific immune responses can be modified by the characteristics of the host, including genetics; age; metabolism; and anatomic, physiologic, and environmental factors (Table 8.2). Host immune systems are discussed in greater detail in Chapter 9.

Physical and Mechanical Barriers Intact physical barriers act as a blockade to foreign material entering the body (Fig. 8.2). Epithelial cells of the skin and those that line the gastrointestinal, genitourinary, and respiratory tracts form sheets that provide a physical barrier to invasion. The constant shedding of the epidermis and mucosal membranes aids in the removal of any micro- organisms that attach to their surfaces. In addition, the high fat content

of treatment-resistant infections. Health care professionals have a vital role in the prevention, early detection, and management of infections.

HOST–MICROBE RELATIONSHIP Microorganisms interact with human hosts in different ways depending on host and microorganism characteristics. Some microorganisms may be encountered in food or water and are of little consequence as they pass through the host without causing harm and without establishing residence in the host. These are called transient microorganisms (Table 8.1). The normal flora that have established long-term residency with the host but do not cause harm, and may even benefit the host, are called commensal. Sometimes commensal organisms may cause oppor- tunistic infections when they gain access to parts of the body where they do not belong or when the host’s immune system is depressed. Other opportunists may be low-virulence, ubiquitous types of organisms that do not cause disease in humans with normal immune systems and only occur in the immunosuppressed. Microorganisms that frequently cause diseases in humans with normal immune defenses are called pathogens. Human pathogens are passed from one human reservoir to another human, either directly or through a fomite (e.g., contaminated instruments, contaminated food). Sometimes humans come into contact with pathogens that do not usually affect humans, through insect or animal bites, for example. These accidental pathogens (see Table 8.1) may cause severe disease in humans.

The Human Microbiome The relationship between the host and the commensal organisms that live in residence is a complex and diverse one that could affect and be

TABLE 8.1 Definitions of Microorganism– Host Interactions Transient A microorganism that is encountered in food

or elsewhere in our environment. In general, it is just “passing through” and of little consequence; however, regular encounters over extended periods might lead to host adaptation or even dependence.

Commensal (literally, those that “eat at the same table”)

A microorganism that is a normal inhabitant of the human body. In commensal relationships, either the microbe or host derives benefit; in mutualistic relationships, both derive benefit.

Pathogen (derived from the Greek, pathos, meaning the “birth of suffering”)

A microbe that may or may not be a member of the indigenous microbiota, but it regularly causes disease in apparently normal individuals.

Opportunistic pathogen A microbe that causes disease only in humans who are in some way compromised in their normal defense mechanisms.

Accidental pathogen A microorganism that is encountered by accidental contact with animals, insects, or the environment. These microorganisms are often deadly in humans and sometimes the causative agent of disease in other animals. These microbes are often distinguished from human-specific pathogens because they are not directly or readily transmissible from human to human.

CHAPTER 8 Infectious Processes 143

of the body’s secretions, where it acts to bind up and prevent entry of microorganisms through mucous membranes. (See Chapter 9 for a discussion about immunoglobulins.)

Removal or degradation of the body’s mechanical and biochemical barriers creates a setting in which infection is likely. For example, burn victims who have lost portions of their skin barrier are at high risk for infection. Destruction and paralysis of the mucocilliary transport system of the lung by smoke inhalation or by insertion of breathing tubes increases the likelihood that pathogens can cause pneumonia. Hospital- ized patients who have incisions or intravenous and urinary catheters are at risk for infection because their skin barrier has been breached. When a urinary catheter is in place, flushing of bacteria from the urinary tract is impaired. Procedures or diseases that allow organisms to leak from the bowel into the peritoneal cavity are a particularly serious breach of a barrier that can result in life-threatening peritonitis.

Impaired Immune Function Impaired function of the immune system is an important risk factor for the development of both opportunistic and pathogenic infections. Immunosuppressive drugs used in the treatment of cancer, autoimmune disorders, and inflammatory disorders are common culprits. However, many other factors can reduce a person’s ability to resist infection, including poor nutritional status, young or old age, and chronic illness. A person who is at high risk for infection must be vigilant to maintain physical barriers and avoid exposures to pathogens through environ- mental controls, including avoidance of infected persons and diligent handwashing. Severely immunocompromised individuals may require isolation until their immune status improves.

Nutritional status. The World Health Organization (WHO) reports that inadequate nutrition is a general risk factor for disease and is a particularly important factor in tuberculosis (TB) infection. Protein- energy malnutrition is associated with defects in cell-mediated immunity (specific), impaired intracellular destruction by neutrophils, reduced complement activity, and decreased levels of secretory IgA. At the time of an illness, nutrition is negatively affected by decreased appetite, mal- absorption, diarrhea, and diversion of nutrients for immune responses, further exacerbating a malnourished state. The presence of fever increases the metabolic rate, requiring more energy and micronutrients. Protein

Mechanical barriers

Phagocytes

Biochemical mediators

Biochemical barriers

Acute illness

Fever Stress

Toxins

Encapsulation

Adhesins

Spore formation

Slime layer

Flagella Enzymes

Pili

Age

Nutrition

Sanitation

Water quality

Crowded living conditions

Weather

Air quality

Seasons

Hygiene

Arthropod bite

Mutation

Chronic illness

ENVIRONMEN T

MICROBE

HOST

FIG 8.1 This depiction of the interactions of host, microbe, and environ- ment provides a framework for understanding infectious processes.

TABLE 8.2 Host Characteristics Influencing Infection

Exposure Host Health

Animals, humans, insects, parasites

Environmental Water, toxins, pollutants, radiation,

sewage Hygiene Toileting, handwashing, dental care,

bathing Social Behaviors Illicit drug use, alcohol, smoking,

risk taking: sexual, sports Travel Exposure to vectors in undeveloped

countries

Intact immune system Absence of chronic disease such as

diabetes Absence of genetic abnormality Nutritional Status Adequate intake of proteins,

vitamins, and minerals Antibiotic Exposure Recent use, noncompletion of

course Development of resistance or

allergy

BIOCHEMICAL AND MECHANICAL

BIOCHEMICAL

Lysozyme in most

secretions Mucus

Cilia lining tracheaSebaceous

gland secretions

Vaginal secretions

Resident flora in gut and

vagina

Skin

Acid in stomach

Prostatic and testicular secretions

FIG 8.2 Some of the mechanical and biochemical barriers of the human body.

of the skin inhibits the growth of bacteria and fungi. The mucous membranes are covered with sticky mucus that traps microorganisms so that they can be removed efficiently. In the lungs, the mucociliary transport system constantly sweeps trapped organisms up and out of the lungs. In the urinary tract, the frequent flow of urine helps mechani- cally sweep out bacteria from the urethra.

Biochemical barriers enhance the effectiveness of the mechanical barriers. The acidic environment of the skin, urine, and vagina inhibits bacterial growth. The secretion of acid into the stomach (with a pH of 1 to 2) results in the killing of many microorganisms. Saliva, mucus, tears, and sweat contain antimicrobial chemicals such as lysozyme, an enzyme that destroys cell walls of gram-positive bacteria. Lactoferrin is a mucosal protein that keeps bacterial replication low by reducing the availability of free iron needed for bacterial growth. Sebaceous gland secretions act as antifungals. Immunoglobulin A (IgA) is found in many

144 UNIT III Defense

host by direct exposure to the altered pathogen without causing disease. The second is to decrease the number of susceptible hosts in the popula- tion, thereby limiting the possibility of transmission of the disease. By this method, known as herd immunity, the disease can be controlled or eliminated without immunizing everyone, as long as a high enough percentage of the population is immunized. The number of susceptible hosts in the population decreases as immunization rates increase. When a critical percentage of the susceptible population is immunized, disease outbreaks can be averted. If the percentage of adequately immunized individuals drops, epidemics may result.

Depending on the immunogenicity of the vaccine, several doses spaced at intervals may be necessary to allow for continued development of an antibody level sufficient to prevent disease. Recent outbreaks of whooping cough (pertussis) and measles have occurred in the United States in areas where the immunization rate has dropped. Perhaps predictably, when vaccines have been effective in preventing diseases for a number of decades, younger parents have not seen the consequences of these diseases and therefore may not feel compelled to vaccinate their children. The Centers for Disease Control and Prevention (CDC) is an important source for tracking infectious disease outbreaks and provides updates and recommendations for immunizations for adults, children, and travelers (www.cdc.gov).

Pathogen Characteristics Pathogens possess certain characteristics that assist in their penetration and survival in the host despite the presence of an intact defense system. Virulence is the term used to describe the potential of microorganisms to cause disease in the host. Microorganisms with high virulence cause disease in human hosts even when their immune systems are intact. Low-virulence organisms have a reduced ability to cause disease and are less likely to cause illness unless other factors favor them, such as immune defects or loss of physical barriers. Bacterial virulence depends on the ability to adhere to host cells, to invade tissues, or to deliver toxins.

Adherence and Invasion The ability to adhere to the contact surface is critical for the success of a microorganism. This ability is affected by the surface hydrophobicity, the net surface charge, the binding molecules on the bacteria (adhesions), and the interaction with the host cell membrane. Many bacteria, such as E. coli, have pili, which are hairlike structures that extend from the bacterial cell wall and help increase attachment of the bacteria to host cells (Fig. 8.3). Other bacteria, such as Streptococcus pyogenes, have hairlike appendages called fimbriae that extend from the cell surface and promote attachment. Most pathogenic bacteria remain outside of the cells, but some are able to enter host cells by binding to particular proteins on the cell surface, such as complement receptors (C3b). Intracellular bacteria may kill the host cell or may remain dormant and hidden from the immune system for a time.

Development of a microbial slime layer also facilitates adherence and improves survival of the pathogen. A thin layer of peptidoglycan is created that can participate in the development of pili or flagella on some organisms.

Bacterial Endotoxin Some bacteria produce substances that are toxic to the host. Some of these bacteria secrete their toxins (see later), and others contain the toxin within the cell wall (endotoxin). Endotoxin is a lipopolysaccharide (LPS) in the membrane of gram-negative bacteria that is highly immunogenic and attracts immune cells to the area of infection and induces the production of inflammatory cytokines (Chapter 9).

malnutrition frequently occurs because of the lack of available clean and safe food.

Micronutrients are also important in immune function. Vitamin A contributes to maintenance of the epithelium, and vitamin E is an antioxidant that supports the development and function of T cells. Vitamin D supports innate and adaptive immunity and promotes immune protection against TB by increasing macrophage defenses. Decreased availability of zinc results in a reduction in neutrophil and natural killer cell function, complement activity, and lymphocyte activity. Iron deficiency is associated with decreased cell-mediated immunity and reductions in neutrophil action. Iron deficiency is one of the most common deficiencies worldwide.

Age. Age affects immune responsiveness as well as the likelihood of exposures to infectious agents. Viruses such as mumps, polio, or Epstein–Barr virus (EBV) cause less severe infection in infants, whereas others such as rotaviruses result in severe illness in infants. These age- related factors may reflect the availability of immune factors or the maturity of the immune system. T-cell function appears to be impaired in newborns, with the majority of the immune response provided by maternal IgG that crossed the placenta. As this immunity fades over approximately the first 6 months of life, these newborns are more at risk of serious infection. Those infants who are breast feeding will obtain secretory IgA, which does provide additional protection. Immunity tends to decline in the elderly, resulting in reduced antibody responses to new antigens. The immune system may become dysregulated in the elderly, as evidenced by the increased frequency of autoimmune diseases with age.

Chronic illness. Chronic illnesses such as diabetes, cancer, heart disease, and renal failure are associated with an increased risk of infection. Deaths in patients with chronic illnesses are frequently directly related to an infectious process. It is difficult to separate the various immune- suppressing components that accompany chronic illness because malnutrition and medications may play a part. Specific chronic illnesses may create a milieu in which pathogens take hold. For example, patients with hyperglycemia often develop genitourinary infections, in part because of the high glucose in the urine. Poor circulation to an area because of vascular disease can also limit the ability of the tissue to withstand infection and may impair the ability of immune cells to gain access to the area. The physiologic response to chronic stress is thought to contribute to risk for infection. Neurohormonal alterations lead to changes in the levels of cortisol and other stress hormones that may affect immune responsiveness (see Chapter 2).

Patients with poorly functioning or inadequate numbers of immune cells are particularly at risk for a wide variety of infectious diseases. Infection with opportunistic organisms that are usually not pathogenic is an indicator that a person is immunocompromised. The immunocompromised status might be a result of genetic disorders (such as hypogammaglobulinemia) or may be acquired (such as in patients who have undergone a splenectomy or have human immunodeficiency virus [HIV]). The prevalence of people with medication-induced immunosuppression is increasing. Antirejection medications such as corticosteroids, cyclosporine, and tacrolimus contribute to immuno- suppression in transplant patients. People who take corticosteroids and immunomodulators to suppress inflammatory and autoimmune diseases are also at high risk of infection. HIV disease is an important chronic condition that predisposes to a variety of other infections (see Chapter 12).

Immunization status. Immunization is the most effective means to reduce morbidity and mortality from vaccine-preventable diseases, such as hepatitis A, hepatitis B, influenza, and pneumococcal infections. There are two goals of immunization: The first is to confer immunity to a

CHAPTER 8 Infectious Processes 145

Endospore Formation Several of the bacteria are capable of creating endospores. In response to the depletion of nutrients such as carbon, nitrogen, or phosphorus, the cell forms an internal spore. These spores are in a resting state that is markedly resistant to heat, chemical agents, and desiccation. When the environment is more favorable, spores are reactivated. Common bacteria with this ability include Bacillus and Clostridium.

Antimicrobial Resistance At least eight mechanisms of bacterial resistance to drugs are known: 1) Enzymatic inhibition: Bacteria can produce enzymes that inactivate drugs (e.g., β-lactamase can inactivate penicillins). 2) Reduced perme- ability: Bacteria can reduce the permeability of their membranes to the antibiotic by down-regulation or loss of specific water-filled pores called porins that drugs use to enter the bacterial cell. 3) Alteration of target site: Bacteria can create a modified target that is no longer as susceptible to the antibiotic. For example, a number of antibiotics bind to bacterial ribosomes to interrupt protein synthesis, but bacteria may change the binding site of the ribosome (by methylation, for instance) so that the drug no longer binds. 4) Protection of target site: Bacteria may produce new proteins that protect or stabilize the target against the drug. 5) Overproduction of target: Simply producing a large quantity of targets within the bacteria can make them resistant by binding up the drug to target, yet having a surplus of target that can maintain activity. 6) Bacteria can employ an export mechanism that uses an ion gradient (H+) to actively pump out the drug. 7) The bacteria can develop a workaround to bypass the process that is affected by the drug. For example, the bacteria may develop a way to obtain needed substrates from the environment rather than producing them. 8) Bacteria may develop a molecule (e.g., glycoprotein) to bind up the antibiotic before it has a chance to affect the bacterial cell processes. Usually these resistant properties develop by chance mutations in the organisms; however, some bacteria may be able to transmit their resistance to other bacteria through gene transfer.

Resistant infections occur because of natural, random genetic dif- ferences in the population of organisms that affect their susceptibility to antibiotics. The susceptible strains die, and the resistant strains emerge after exposure to antibiotics, creating a drug-resistant infection. Antibiot- ics do not cause mutations in bacteria and therefore don’t cause resistance; however, excessive use of antibiotics and subtherapeutic dosing contribute to the emergence of resistant infections. Relatively resistant microorgan- isms survive a low-dose antibiotic course to become the dominant species and may then be transmitted to other individuals. Generally, when the antibiotic is no longer present, the resistant strains no longer have a growth advantage and will diminish.

The rapid development of antibiotic resistance in bacteria can occur when bacteria transmit their resistance genes to other bacteria. Bacteria are subjected to infections of their own in the form of plasmids and bacteriophages that can transfer genes between microorganisms. These mobile genetic elements can be transmitted through conjugation (bacterial sexual reproduction) or by infection of the bacteria (bacte- riophages). The possibility of transfer of microbial resistance through mobile genetic elements is a greatly feared outcome that could produce virulent, multidrug resistant strains quite rapidly. More resistant bacteria in the environment because of antibiotic use increase the chance that mobile genetic elements could be transferred among them. Some common pathogens and their mechanisms of antimicrobial resistance are shown in Table 8.3. Susceptibility of a bacterial infection to particular antibiotics can be evaluated by culture and sensitivity testing. An example of common sensitivity testing results is shown in Box 8.1.

Unfortunately, when endotoxin is released by immune destruction of the bacteria, the resulting immune activation can have profound effects on the host, causing septic shock, intravascular coagulation, and respira- tory failure (see Chapter 20 for a discussion of shock).

Bacterial Exotoxins and Enzymes Exotoxins are secreted by some types of bacteria and can cause havoc, even when the bacteria that made the toxin are no longer present. Neurotoxins produced by Clostridium botulinum and Clostridium tetani interfere with synaptic transmission at the neuromuscular junction, resulting in paralysis and respiratory failure. Like endotoxin (LPS), some secreted exotoxins are extremely good at activating the immune system to such a degree that the immune response can cause shock. For example, Staphylococcus aureus antigens can cause toxic shock syndrome.

Some bacteria produce tissue-degrading enzymes. These enzymes degrade certain body tissues, promoting continued disease. For example, S. aureus secretes coagulase, which coagulates plasma and contributes to the formation of fibrin walls around the lesions caused by these bacteria. This allows the bacteria to persist in the cellular environment. The coagulase also causes deposits of fibrin on the bacteria itself, leading to improved protection from phagocytosis.

Other bacteria produce hyaluronidase, which is an enzyme that breaks down hyaluronic acid. This acid is present in connective tissue. This action helps disseminate the bacteria through the tissues. Some bacteria are able to produce substances that are cytolysins. These cytolysins can dissolve red blood cells, tissue cells, or leukocytes. For example, group A streptococci produce streptolysin O, which lyses red blood cells.

Evasion of Immune Cells Some bacteria develop an outside coating on their surface to prevent phagocytosis. The coating can be made of host cell components or a polysaccharide capsule. Some bacteria form interactive colonies that produce a polysaccharide matrix called biofilm. This slimy coating on solid surfaces can involve a single species or several species. These bacteria can be difficult to dislodge and may be hidden and protected from the host’s immune mechanisms. An important and well-known example is the biofilm that forms on tooth enamel, commonly called plaque.

FIG 8.3 Bacterial pili increase properties of adherence and may increase virulence. (From Rosenshine I, et al: A pathogenic bacterium triggers epithelial signals to form a functional bacterial receptor that mediates actin pseudopod formation. The EMBO Journal, 1996;15(11): 2613–2624.

146 UNIT III Defense

TABLE 8.3 Resistance Mechanisms Found in Common Bacterial Pathogens

Pathogen Resistance Phenotype Major Resistance Mechanism

Streptococcus pneumoniae

β-Lactams Alteration of target enzymes (PBPs) Macrolides, lincosamides, streptogramin B Alteration of ribosomal target sites (methylation of adenine residue in

domain V of 23S rRNA—ermB); efflux (mefE) Tetracycline Protection of ribosomal target site (tetM) Trimethoprim and sulfonamides Alteration of target enzymes (dihydrofolate reductase–trimethoprim;

dihydropteroate synthase—sul1, sul2 in sulfonamines) Fluoroquinolones Alteration of target enzymes (DNA gyrase—gyrA mutations; topoisomerase

IV—parC mutations) Staphylococcus aureus β-Lactams Enzymatic inhibition (penicillinase production)

Penicillin Methicillin, oxacillin, nafcillin, and cephalosporins

(MRSA)

Alteration of target enzyme—PBP2a (mecA)

Glycopeptide GISA Alteration of cell wall precursor targets (thickened cell wall binds drug, preventing it from reaching its target)

GRSA Alteration of cell wall precursor targets (plasmid-mediated transfer of vanA genes from VRE, resulting in d-ala-d-lac peptidoglycan precursors)

Enterococci β-Lactams (ampicillin) Alteration of target enzymes (PBP5 in Enterococcus faecium); enzymatic inhibition–rare (penicillinase in E. fecalis)

Aminoglycosides Altered ribosomal target site mutations, enzymatic inhibition (high-level resistance: aminoglycoside-modifying enzymes)

Vancomycin Alteration of cell wall precursor targets (high-level resistance: VanA, B, D phenotypes; low-level resistance: VanC, E, G phenotypes)

Linezolid Alteration of ribosomal target sites (G2576U mutation in domain V of 23S rRNA)

Quinupristin-dalfopristin Enzymatic inhibition; efflux; target modification (E. faecium) Neisseria gonorrheae Penicillins PPNG: enzymatic inhibition (plasmid-acquired penicillinase); CRNG: altered

target enzymes (PBPs) Fluoroquinolones Alteration of target enzymes (DNA gyrase; topoisomerase IV); efflux

(MtrR-CDE efflux system) Tetracycline Protection of ribosomal target (tetM gene) Macrolides Efflux; alteration in ribosomal targets (C2611T mutation in domain V of the

23S rRNA) MDR Efflux (MtrR-CDE system: penicillin, tetracycline, macrolides)

Pseudomonas aeruginosa β-Lactams Enzymatic inhibition (AmpC cephalosporinases, extended-spectrum β-lactamases, metallo-β-lactamases); active efflux (MexAB); reduced outer membrane permeability (loss of OprD channel)

Aminoglycosides Enzymatic inhibition (aminoglycoside-modifying enzymes); efflux (MexXY); alteration of ribosomal targets (ribosomal methylation)

Fluoroquinolones Efflux (MexAB, CD, EF, XY, GH, VW); alteration of target enzymes (DNA gyrase mutations—gyrA)

MDR Overexpression of the MexA-MexB-OprM active efflux system (resistance to quinolones, tetracyclines, and trimethoprim)

Acinetobacter baumannii β-Lactams Enzymatic inhibition (AmpC cephalosporinases, plasmid-acquired β-lactamases of the TEM, SHV, CTX-M, PER, VEB families, metallo-β- lactamases of the IMP, VIM, SIM families, and OXA-type serine carbapenemases); alteration of target enzymes (PBPs); reduced outer membrane permeability; efflux pumps

Aminoglycosides Enzymatic inhibition (aminoglycoside-modifying enzymes); efflux pumps Quinolones Efflux pumps Tigecycline Efflux pumps

Stenotrophomonas maltophilia

β-Lactams Impermeable outer membrane Enzymatic inhibition (inducible metallo-β-lactamases L1, L2)

TMP-SMX Alteration in sulfonamide target enzymes (sul1, sul2 genes—associated with plasmids or class 1 integrons)

Fluoroquinolones Alteration of target enzymes (DNA gyrase mutations); efflux pumps MDR MDR efflux pump (smeDEF confers resistance to tetracycline, erythromycin,

chloramphenicol, norfloxacin, ofloxacin)

CHAPTER 8 Infectious Processes 147

TRANSMISSION OF INFECTION The transmission of microorganisms requires an unbroken chain of events to enable one host to transmit the infection to another (Fig. 8.4). Pathogens must live and reproduce in a reservoir. The reservoir may be a human, as in the influenza virus; an animal, as in rabies; an

TABLE 8.3 Resistance Mechanisms Found in Common Bacterial Pathogens—cont’d

Pathogen Resistance Phenotype Major Resistance Mechanism

Klebsiella pneumoniae β-Lactams Enzymatic inhibition (constitutive expression of penicillinases; extended- spectrum β-lactamases; KPC, NDM-1 carbapenemases); decreased outer membrane permeability

Fluoroquinolones Alteration of target enzymes (DNA gyrase mutations—gyrA); efflux; protection of target site (plasmid-mediated qnr genes)

Aminoglycosides Enzymatic inhibition (aminoglycoside-modifying enzymes); alteration of ribosomal targets (ribosomal methylation)

Bacteroides spp. β-Lactams Enzymatic inhibition (chromosomally encoded CepA cephalosporinases; metallo-β-lactamases); efflux (homologues of RND-pumps); alteration in drug targets (PBPs)

Macrolides, lincosamides, streptogramin B Alteration of ribosomal targets Tetracycline Protection of ribosomal target (tetQ); efflux Quinolones Alteration of target enzymes (DNA gyrase mutations—gyr A); efflux

CRNG, Chromosomally resistant N. gonorrheae; CTX-M, cefotaxime-M; GISA, glycopeptide intermediate S. aureus; GRSA, glycopeptide-resistant S. aureus; IMP, imipenem; KPC, K. pneumoniae carbapenemase; MDR, multidrug resistance; MRSA, methicillin-resistant S. aureus; MtrR, multiple transferable resistance; NDM-1, New Delhi metallo-β-lactamase–1; PBPs, penicillin-binding proteins; PER, Pseudomonas extended resistance; PPNG, penicillinase-producing N. gonorrheae; RND, resistance-nodulation-cell division; rRNA, ribosomal RNA; SHV, sulfhydryl variable; SIM, Seoul imipenemase; TEM, Temoneira; TMP-SMX, trimethoprim-sulfamethoxazole; VEB, Vietnam extended-spectrum β-lactamase; VIM, Verona integron-encoded metallo-β-lactamase; VRE, vancomycin-resistant enterococci. From Bennett J, Dolin R, Blaser, M: Mandell, Douglas, and Bennett’s principles and practice of infectious diseases, ed 8, Philadelphia, 2015, Saunders, p 247.

KEY POINTS • A number of microorganisms are considered resident flora because they

live on or in the host without causing disease. Resident flora and probiotics benefit the host by synthesizing molecules and inhibiting the growth of nonresident microorganisms. If the host’s immune system is compromised, resident flora may become pathogenic and cause opportunistic infection.

• Microorganisms possess characteristics that enhance their pathogenic potential. Adherence is improved by the presence of adhesion molecules, slime layers, and pili. Escape from immune detection and destruction is enhanced by encapsulation, spore formation, mutation, use of flagella, and toxin production. Microorganisms that possess these advantageous char- acteristics are more virulent and thus more likely to cause disease.

• Drug resistance occurs when microorganisms undergo chance mutations that allow them to survive in the presence of an antibiotic. When the antibiotic is present, these resistant strains emerge to become the dominant species in an individual and may be transmitted to others, causing resistant infections.

• Immunizations alter the susceptibility of the host by stimulating the immune system to create antibodies to the pathogen.

Culture Urine Colony Count Specimen Source Urine Result > 100,000 Organisms/mL Escherichia coli Report Status Final

Susceptibility Testing Cefazolin Susceptible Gentamicin Susceptible Levofloxacin Susceptible Minocycline Susceptible Nitrofurantoin Susceptible Oxacillin Susceptible Trimethoprim/Sulfa Resistant Vancomycin Susceptible

BOX 8.1 Example of the Results of Bacterial Culture and Sensitivity Testing

Human Animal Insect Soil

Nasal mucosa Oral mucosa

Nasal mucosa Oral mucosa Skin abrasion Skin puncture

Insect bite Nasal droplets Semen

Malnourished Unimmunized Immune compromised

RESERVOIR

RESERVOIR

PORTAL OF EXIT

PORTAL OF EXIT

PORTAL OF ENTRY

PORTAL OF ENTRY

MODE OF TRANSMISSIO N

M O

D E

O F TRANSMISSION

SUSCEPTIBLE VICTIM

S U S CEPTIBLE VICTIM

FIG 8.4 Chain of transmission of microorganisms from host to victim.

insect, as in West Nile virus; or soil, as in enterobiasis (pinworm infestation). The pathogen must have a portal of exit and a mode of transmission from the reservoir to a susceptible host, where it finds a portal of entry. Some microorganisms can survive outside the reservoir for a time, whereas others must be transmitted from host to host by direct contact.

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Mosquito eradication Garbage disposal Sewage treatment

Masking Gloving Isolation Condom use

MaskingGloving Condom use

Sterile techniq ue

Body substan ce isolation

Hand washing

Thorough coo king of food

Vaccination Optimal rest Optimal nutrition

DESTROYING

RESERVOIR

BLOCKING

BLOCKING

BLOCKING

PORTAL OF EX IT

PORTAL OF ENTRY

M O D E OF TRANSM

IS SI O

N

VIC TIM’S SUSCEPTIB ILI T Y

REDUCING

FIG 8.5 Breaking the chain of transmission of microorganisms from host to victim.

Routes of Transmission There are three common routes of direct transmission of pathogens. The most common is through the exchange of body fluids (droplets) from kissing or sexual intercourse. In this type of transmission, droplets are spread from an infected host to the conjunctiva or mucous membranes of a second host. The second type of direct transmission occurs from the bite of an animal (e.g., rabies) or from contact with contaminated soil (e.g., systemic mycosis). The third type of direct transmission occurs through the placenta when diseases such as HIV are transmitted directly to the fetus. This is called vertical transmission.

Indirect transmission occurs as vehicle-borne, vector-borne, or airborne transfers. A vehicle-borne transfer occurs when an infectious agent is transported to the host. The vehicle could be food, water, clothing, plasma, or tissues. The agent does not require any development or multiplication and is delivered without change with the vehicle. Airborne transmission occurs with aerosols, including suspensions of particles (smaller than the size of droplets), which can be carried great distances from the source for transmission. Examples are outbreaks of measles and legionnaires disease. Vector-borne transmission can occur as a mechanical or biological transfer. The mechanical transfer occurs when an insect carries an infectious agent on its feet or proboscis. In this transfer the agent does not require multiplication or development before transfer. This is in contrast to biological vector-borne transport. In this type of transmission, the agent propagates and there is cyclic development before the arthropod can transmit the disease.

Control of the spread of infectious disease depends on breaking the chain of transmission in one or more places (Fig. 8.5). Therefore it is critical to understand the life cycle and transmission patterns (epidemiol- ogy) of different pathogens—a top priority of the CDC. An infectious disease that has a fairly constant presence in a community and changes little from year to year, such as the sexually transmitted disease Chlamydia, is classified as endemic. A significant increase in new infections in a certain population, such as a measles outbreak at a university, is termed an epidemic. An epidemic that has spread to a large geographic area is a pandemic. The bubonic plague, which caused 100 million deaths worldwide in the 1300s, was a pandemic.

Destroying nonhuman reservoirs and vectors of the pathogen can break the chain of transmission. For example, controlling the number of mosquitoes with insecticides and other biological means is a method used to curb the spread of malaria and West Nile virus. Immunization

of domesticated animals against rabies eliminates one reservoir of potential rabies transmission. Distribution of clean needles in the intravenous drug user community is aimed at removing a common transmission vector (contaminated needles) for HIV, the causative pathogen responsible for acquired immunodeficiency syndrome (AIDS).

Blocking the portal of exit can also block transmission of the pathogen. Having patients with TB wear face masks while they move through the hospital and implementing respiratory isolation techniques to stop transmission are interventions aimed at blocking the portal of exit. Standard precautions are infection-control guidelines designed to block the pathogen’s portal of exit, route of transmission, and portal of entry. Handwashing is one of the most effective ways to break the chain of transmission by blocking an important mode of transmission— contaminated hands.

Multiple environmental factors affect the prevalence and transmission of various infections and infestations. For example, parasitic infections are facilitated by hot and humid climates, overcrowded living conditions, the presence of insect vectors in bed linen or clothing, improper sewage disposal or treatment (such as the use of raw human sewage as fertilizer), the lack of clean water, and the consumption of contaminated raw or undercooked meat or vegetables.

Infections may be transmitted by inhalation of polluted dust or air. For example, the fungus Coccidioides immitis, which causes valley fever, is pandemic in the southwestern United States. Toxoplasmosis is caused by inhalation or ingestion of dirt, sand, or litter dust contaminated with cat feces that contain the causative protozoon Toxoplasma gondii. The plague is still a disease of concern in many countries. It is caused by the bacterium Yersinia pestis, which is carried by a rodent flea. There are multiple examples of foodborne illness such as Salmonella, with outbreaks related to improper processing, storage, or cooking of meats and raw produce.

Emerging Infectious Diseases Pathogens can spread faster and in greater numbers due to global transport networks and world travel. Global growth, migration, and tourism are largely responsible for the threat of locally emergent diseases to escalate toward large-scale pandemics. For example, coronaviruses (CoVs) are general respiratory tract infections that infect a wide range of mammals and are symptomatic of the common cold. Recently, however, certain CoV infections, such as severe acute respiratory syndrome (SARS-CoV) in 2002 and Middle East respiratory syndrome (MERS-CoV)

CHAPTER 8 Infectious Processes 149

TYPES OF PATHOGENIC ORGANISMS A large number of different types of microorganisms pose an infection risk for humans (Fig. 8.6). The chapter thus far has focused mainly on bacterial pathogens. Many bacterial infections are treatable with antibiot- ics, and there is much focus on them for that reason. Viral infections are difficult to treat effectively, and the primary focus has been on finding vaccines for them. Fungal and parasitic infections are also important contributors to human disease, particularly in immunocompromised hosts and in areas with contaminated water supply. Prion infection is from a protein and not an organism at all. Each of these infectious agents is discussed briefly, with a focus on common causes of infection.

Bacteria Bacteria are single-celled, rigid-wall organisms that have no internal organelles (Fig. 8.7). Some live in the intestines of humans or other animals and participate in digestion. Others live in the soil and are responsible for its fertility. They degrade dead tissue into useful components for other organisms to use. Among the countless types of bacteria that exist, only a small percentage is known to be harmful to humans. Some bacteria that are associated with infections of various sites are shown in Box 8.2.

Bacteria have a variety of shapes, including cocci (spherical), bacilli (rod-shaped or comma-shaped rods, e.g., Pseudomonas aeruginosa vibrio), or spiral (twisted rod shaped, e.g., Spirillum). Those classified as cocci are also seen in clusters, chains, pairs, or tetrads. The majority of bacteria that cause disease in humans are one of these true bacteria. Filamentous bacteria may have branching structures that resemble fungi. Mycobac- terium tuberculosis would be an example.

Spirochetes (the majority of which are anaerobic) possess a motile spiral filament (e.g., Treponema pallidum). Bacteria of the genus Mycoplasma do not have a rigid cell wall and are pleomorphic (many formed) in shape. They are some of the smallest of the bacteria; an example is Mycoplasma pneumoniae, which causes an atypical pneu- monia. Rickettsia is a genus consisting of intracellular parasites that can have a variety of shapes. Vectors usually spread this group; for example, Rocky Mountain spotted fever is caused by Rickettsia rickettsii and transmitted by ticks. Chlamydia are also intracellular parasites, but have a more complex life cycle, with Chlamydia trachomatis as an example.

Bacteria are classified not only by morphology (shape) but also by the response to gram staining. Gram staining separates bacteria into gram-positive organisms, which appear dark purple under the micro- scope; gram-negative organisms, which appear pink; or acid-fast organisms, which resist staining but, once stained, resist discoloration. Further differentiation of bacteria is based on nutritional requirements (such as whether the organism is anaerobic or aerobic), on colony characteristics, and on resistance.

in 2012, emerged as serious diseases in humans. The SARS and MERS viruses emerged from zoonotic animal-to-human transmission and caused serious and sometimes fatal lower respiratory infections. The WHO reported that SARS infected 8096 people, resulted in 774 deaths, and was spread globally by human-to-human contact from 2002 until its eradication in 2004. MERS virus has claimed 291 lives of 837 confirmed cases since 2012 and has remained at large with unknown pathology in humans (WHO last reported July 23, 2014).

The single largest Ebola outbreak to date was documented in March 2014 in Guinea, West Africa. By August 8, 2014, the outbreak had spread to neighboring regions and was declared an epidemic and an international public emergency by the WHO. The WHO reported on September 13, 2015, that Ebola virus had claimed 11,306 lives of the 28,256 reported cases, 17 of which were treated outside Africa and 4 of whom died.

The Zika virus is a flavivirus spread by Aedes mosquitos and has no known treatment. Zika virus was mostly ignored until recently because of usually mild symptoms; however, in 2016 the Zika virus was correlated with significant developmental defects such as the severe brain malforma- tion microcephaly. Microcephaly is a brain disorder that results in a smaller-than-normal head size and mental disability. It was also discovered that in addition to being carried by mosquitos, Zika can spread via sexual intercourse. In 2016 the CDC issued a comprehensive travel guide that warded off travel and set up warnings for the affected areas, especially for pregnant women, until more could be understood about the virus.

Modern medicine has eradicated many potentially fatal diseases with vaccination programs. Conversely, recent reports indicate that preventable disease outbreaks such as the measles, mumps, and whooping cough spiked in the United States and abroad, in part because of antivaccination movements. The CDC’s National Center for Immunization and Respira- tory Diseases recently reported the largest measles outbreak since its near eradication in 2000. A record 668 measles cases occurred throughout 27 states in 2014. The antivaccination movement was based on the speculative correlation of an increased diagnosis of autism with increased childhood vaccinations. This idea was promoted by fraudulent research that has since been retracted. However, significant segments of the population continue to avoid vaccinations for their children.

Weapons of Bioterrorism Crude forms of weaponized infectious diseases have been around since 600 BC when plagued cadavers, filth, or pollution were used to weaken an enemy. Unfortunately, the use of biological warfare became more sophisticated throughout the nineteenth and twentieth centuries. Wartime efforts spurred the development and testing of weaponized pathogens. For example, “Unit 731” was a World War II Japanese biowarfare program that was believed to have executed more than 10,000 prisoners with weaponized Bacillus anthracis, Neisseria meningitidis, Vibrio cholerae, etc. Modern domestic bioterrorism in the United States has been largely isolated, extremist, or cult sponsored and resulted in a minimal death toll, but these events serve as a wake-up call for bioterrorism fortification, reducing risk of exposure, and improving public health surveillance.

KEY POINTS • Transmission of disease requires a chain of events that includes passing

of the pathogen from the reservoir of the infection through a portal of exit to a susceptible host through a portal of entry by a circumscribed mode of transmission.

• Environmental factors influence the likelihood of exposure and infection by microorganisms. Sanitation, air quality, living conditions, and climate are important factors.

• The spread of emergent infectious disease is further facilitated by a global society. For example, severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and Ebola outbreaks were pinpointed in isolated regions, yet human-to-human contact carried these pathogens elsewhere and resulted in worldwide epidemics.

• Dangerous pathogens designed for bioterrorism present proximate dangers to public health.

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Fig. 8.8 depicts examples of pathogenic bacteria and the areas that they commonly infect. Colonies are formed when bacteria penetrate initial defense mechanisms and multiply. In an attempt to contain and eliminate the invading bacteria, an acute inflammatory reaction occurs. Phagocytic cells such as neutrophils and macrophages are recruited to the area, where they ingest and destroy the microorganisms. If these responses are insufficient to contain the infection, the bacteria move through the body in natural currents of fluids (i.e., bloodstream, lymph system, or interstitial fluids). Bacteria may move through the lymph system to the lymph nodes, where they stimulate an immune response. If they are present in sufficient numbers to overwhelm the lymph nodes, circulating clumps of bacteria (emboli) can cause bacteremia and microabscesses. In severe cases, sepsis, hypotension, organ system failure, and death can occur (see Chapter 20).

Viruses Viruses, the smallest known infective agents, range in size from 20 to 300 nm. They consist of a protein shell called the capsid and a core of genetic material made of either ribonucleic acid (RNA) or deoxyribo- nucleic acid (DNA). The capsid can be in many shapes, including helical, icosahedral, or large pleomorphic shapes. Some viruses also have a protective envelope surrounding the capsid that is obtained from the cell membrane of an infected host cell.

Viruses are classified as RNA or DNA viruses and as either single- stranded (ss) or double-stranded (ds). Some RNA viruses, called ret- roviruses, contain the enzyme reverse transcriptase and can convert their RNA into DNA that can be incorporated into the host’s DNA. The HIV virus is an example of a retrovirus (see Chapter 12). A

A

E F

B C D

G

FIG 8.6 Examples of pathogenic organisms. A, Prion (infectious protein). B, Viruses (the human immuno- deficiency virus [HIV] that causes AIDS). C, Bacteria (Streptococcus bacteria that cause strep throat and other infections). D, Fungi (yeast cells that commonly infect the urinary and reproductive tracts). E, Fungi (the mold that causes aspergillosis). F, Protozoa (the flagellated cells that cause traveler’s diarrhea). G, Pathogenic animals (the parasitic worms that cause snail fever). (A, from Donne DG, et al: Structure of the recombinant full-length hamster prion protein PRp (29-231): the N terminus is highly flexible. Proc Natl Acad Sci USA. 1997;94:13452–13457. Copyright National Academy of Sciences, USA; B, from Lennart Nilsson C-G, from Patton KT, Thibodeau GA: Anatomy & physiology, ed 8, St Louis, MO, 2013, Mosby, p 26.)

CHAPTER 8 Infectious Processes 151

Fungi Fungi are eukaryotic microorganisms with the ability to form complex structures with thick, rigid cell walls. They can grow as a mold with branched filaments or as a meshwork-type structure. Yeasts are a type of fungi with ovoid or spherical shapes. In contrast to bacteria, which have no organelles, the cytosol of fungi does contain organelles. Infec- tions caused by fungi are called mycotic infections, or mycoses. Fungi cause infection first by colonizing the area. The fungus adheres to and proliferates on the site of infection. The next phase requires invasion of the epithelium. Anything that breaks the integrity of the skin (e.g., maceration) facilitates invasion. Polymorphonuclear leukocytes attempt to phagocytize and digest the invading fungi. Neutrophils, monocytes, and eosinophils can destroy fungi in the body.

Certain fungi live in the body as normal flora (e.g., Candida). When the body’s defense mechanisms are compromised, they can overgrow and cause local or systemic infections. Patients who have been given antibiotics generally lose some of their resident flora along with the targeted pathogen. Fungi not affected by these antibiotics overgrow to fill the void niche. Some patients suffering from AIDS, leukemia,

A

B

C

Cocci

Glycoprotein

Envelope

Capsomer

Nucleic acid

Capsid

Core protein

Nucleocapsid

Bacilli

Spirochetes

Microscopic Morphology of Bacteria

FIG 8.7 Types of microorganisms. A, Bacteria. B, Virus. C, Fungus. (A, from Mahon CR, et al: Textbook of diagnostic microbiology, ed 4, Philadelphia, 2011, Saunders; B and C, from Nisengard RJ, Newman MG: Oral microbiology and immunology, ed 2, Philadelphia, 1994, Saunders.)

comparison of viruses, transmission characteristics, and resulting disease processes is presented in Table 8.4.

DNA viruses (e.g., herpes simplex virus) enter the nucleus of the host cell and produce messenger RNA (mRNA) by commandeering the host cell’s enzymes. Viral proteins are then formed from the mRNA, and the DNA of the virus is replicated by host polymerases. DNA and proteins are assembled into new viruses in the host cell. The RNA viruses replicate within the cytoplasm, and most produce mRNA that is then translated into proteins and genomic RNA, from which new viruses are created.

Transmission of a virus occurs from one infected person to another or from an animal reservoir (zoonotic infection). The steps of the viral life cycle include attachment to the target cell as the initial step. The virus then penetrates the cell membrane in various ways. Once inside the host cell, the virus uses the host cell’s materials to produce new viral components. The virus may be released from the host cells by budding from the cell’s surface. Viruses that do not manu- facture an envelope are usually released by lysing the host cell, thus destroying it.

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Systemic mycoses may occur in both healthy and immunocompromised hosts. Because the fungi causing systemic infections are usually found in soil, these infections tend to be endemic to certain regions where the fungus is found. Infection is caused by inhalation of dust containing the fungus. Because of the endemic nature of these fungi, large segments of the population in the area may have been exposed and infected without any symptoms. If symptoms develop, they are usually self-limiting and mild. However, for those with compromised immune systems, the disease may become severe. Examples of systemic mycoses are histo- plasmosis, blastomycosis, and coccidiomycosis. Histoplasma capsulatum is a fungus that commonly occurs in soil in the central and eastern United States. Histoplasma also occurs in soil rich with chicken feces or bat guano. Humans and animals exposed to dust storms in endemic areas or contaminated with these feces are most likely to be infected. They may also have positive histoplasmin skin tests and may show calcified sites of infection in their lungs.

Parasites Parasites establish themselves and benefit from another organism. They range in size from a small unicellular protozoan to large worms. Parasites are representative of four families of the animal kingdom: protozoa, or

alcoholism, drug abuse, and malnutrition or those being treated with immunosuppressive agents lack a well-functioning immune system that prevents fungi from overgrowing and are therefore more susceptible to fungal infections (opportunistic fungi). When the environment contains more nutrients on which the fungi can grow, such as the hyperglycemic bloodstream of a diabetic patient or the vaginal tract of a female taking antibiotics, fungi can overgrow and cause infections. Pneumocystis carinii was reclassified as a fungus in 2006 and renamed Pneumocystis jiroveci. This opportunistic infection is commonly associated with HIV disease.

Superficial mycoses, such as those caused by dermatophytes (e.g., tinea pedis), occur only on superficial, dead, keratinized tissue like hair, epidermis, and nails. Cutaneous fungi do not invade the tissues, but do result in an inflammatory response, as in tinea pedis (athlete’s foot). Subcutaneous mycoses occur when fungi are introduced into subcutaneous tissues and can be seen in ulcers or abscesses on the skin. Systemic infections are invasive to lungs and other organs (e.g., Cryptococcus neoformans). Systemic treatment is commonly used for immunocompromised patients or for patients with disseminated disease because skin infection is usually self-limited. Topical antifungal drugs may be used to treat these superficial infections. Table 8.5 summarizes some examples of fungal infections.

Skin and Wound Infections Staphylococcus aureus Streptococcus pyogenes (group A) Gram-negative bacilli Treponema pallidum Pseudomonas aeruginosa Anaerobic streptococci Clostridium spp. Enterococcus Bacteroides spp.

Brain and Meninges Neisseria meningitidis Haemophilus influenzae Streptococcus pneumoniae Streptococcus spp. Escherichia coli Gram-negative bacilli Streptococcus pyogenes (group A) Staphylococcus aureus Mycobacterium tuberculosis Listeria monocytogenes Enterococcus (neonatal period) Treponema pallidum Leptospira Streptococci (aerobic and anaerobic) Bacteroides spp.

Ear, Nose and Throat Streptococcus pneumoniae Streptococcus pyogenes (group A) Haemophilus influenzae Gram-negative enteric bacilli Pseudomonas aeruginosa Anaerobic streptococci Staphylococcus aureus Neisseria gonorrheae Bacteroides spp.

Fusobacterium Spirochetes Corynebacterium diphtheriae Bordetella pertussis

Lungs and Pleura Mycoplasma pneumoniae Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus Klebsiella Pseudomonas aeruginosa Gram-negative bacilli Streptococcus pyogenes (group A) Mycobacterium tuberculosis Chlamydia psittaci Legionella pneumophila Anaerobic streptococci Bacteroides spp. Coxiella burnetii Fusobacterium Enterococcus

Endocardium Viridans group of streptococci Staphylococcus aureus Enterococcus Other streptococci Staphylococcus epidermidis Gram-negative enteric bacilli Pseudomonas aeruginosa

Peritoneum and Biliary Tract Escherichia coli Gram-negative bacilli Enterococcus Bacteroides fragilis Anaerobic streptococci

Clostridium spp. Streptococcus pneumoniae Streptococcus pyogenes (group A) Neisseria gonorrheae Mycobacterium tuberculosis Staphylococcus aureus

Kidney Escherichia coli Gram-negative bacilli Staphylococcus aureus Staphylococcus epidermidis Mycobacterium tuberculosis

Genitourinary Tract Neisseria gonorrhoeae Chlamydia trachomatis Trichomonas vaginalis Ureaplasma urealyticum Gram-negative enteric bacilli Staphylococcus aureus Mycobacterium tuberculosis

Bone (Osteomyelitis) and Joint Staphylococcus aureus Salmonella Gram-negative enteric bacilli Streptococcus pyogenes (group A) Mycobacterium tuberculosis Anaerobic streptococci Pseudomonas aeruginosa

Joints Neisseria gonorrheae Streptococcus pneumoniae Neisseria meningitidis Haemophilus influenzae (in children)

BOX 8.2 Examples of Bacteria Associated With Specific Infections

CHAPTER 8 Infectious Processes 153

EYES Chlamydia trachomatis

Streptococcus pneumoniae Staphylococcus aureus Neisseria gonorrhoeae

THROAT Corynebacterium

diphtheriae Streptococcus pyogenes

Bordetella pertussis

BRAIN AND MENINGES

Haemophilus influenzae Neisseria meningitidis Streptococcus pneumoniae

Streptococcus pneumoniae Haemophilus influenzae Gram-negative enteric bacilli

Streptococcus viridans Staphylococcus aureus Enterococci

Gram-negative bacilli Escherichia coli

HEART

Staphylococcus aureus Neisseria gonorrhoeae Streptococcus pyogenes

JOINTS

KIDNEY

EAR

LUNGS Mycoplasma pneumoniae

Legionella pneumophila Streptococcus pneumoniae

Haemophilus influenzae Mycobacterium tuberculosis

LIVER Clostridium Enterococci

Gram-negative bacilli

INTESTINES Clostridium difficile

Clostridium perfringens Salmonella

Shigella

VAGINA AND UTERUS Neisseria gonorrhoeae Chlamydia trachomatis

Gram-negative bacilli

SKIN Staphylococcus aureus

Streptococcus pyogenes

Gram-negative bacilli Neisseria gonorrhoeae

PROSTATE AND TESTES

Gram-negative enteric bacilli Mycobacterium tuberculosis

Staphylococcus aureus

BONE

Neisseria gonorrhoeae Chlamydia trachomatis Gram-negative enteric bacilli

URETHRA

FIG 8.8 Examples of pathogenic bacteria classified according to the part of the human body that they commonly infect.

single-celled animals (Fig. 8.9); nemathelminths, or roundworms; platy- helminths, or flatworms; and arthropoda, or invertebrate animals with jointed appendages. These parasites live on or in the human body during some part of their life cycle. Parasites and protozoa are rarely transmitted by human contact; usually they are disseminated through a vector where the parasite or protozoan spends part of its life cycle. For example, malaria (Plasmodium sp.) is transmitted via mosquitoes. Many of the protozoal infections are transmitted through contaminated water or food and require ingestion (e.g., Giardia lamblia). Some parasites have specific surface glycoproteins that influence their ability to enter macrophages.

Host resistance depends on macrophages, neutrophils, eosinophils, and platelets that kill both protozoa and worm parasites. T cells are required to develop immunity against these organisms. The symptoms of parasitic infection depend on the area in which the infestation develops. Protozoan infestation (amebiasis) of the gastrointestinal tract may trigger cramping, abdominal pain, and bloody diarrhea. Infestation of the blood produces fever, chills, rigor, and later anemia, all of which are associated with malaria (Plasmodium infection). Acute pruritus and rash occur after infection of the skin with Sarcoptes scabiei (scabies).

Identification of the infectious agent is usually accomplished by visualization of the adult parasite; by direct observation of the area (inspection of the skin or hair); or by microscopic examination of blood, feces, or tissue samples. Table 8.6 summarizes various parasitic infections of humans, including the common name, location, symptoms, and mode of transmission.

KEY POINTS • Microorganisms responsible for infections in humans include bacteria, viruses,

fungi, and parasites. • Bacteria are characterized according to shape (cocci, rods, spirals), reaction

to stains (gram negative, gram positive, acid fast), and oxygen requirements (aerobic, anaerobic).

• Viruses are small pieces of genetic material (DNA, RNA) associated with proteins and lipids. Viruses are small intracellular pathogens that use the host’s energy sources and enzymes to replicate. Viral replication may or may not destroy the host cell. DNA viruses may be incorporated directly into the host genome. RNA viruses serve as templates for the production of viral RNA and proteins.

• Retroviruses are RNA viruses that contain a special enzyme called reverse transcriptase that mediates the synthesis of a DNA copy of the RNA virus. The DNA can then be incorporated into the host genome and passed on to daughter cells when the cell divides.

• Fungal infections can be superficial (e.g., ringworm, athlete’s foot), subcutane- ous (e.g., sporotrichosis), or systemic (e.g., histoplasmosis). Systemic fungal infections tend to be more serious and usually do not occur unless the host’s immune system is compromised.

• Parasites include protozoa, helminths (roundworms, flatworms), and arthropods. Manifestations of parasitic infections vary depending on the organism and site of infection. Common sites of parasitic infestation are the skin and gastrointestinal tract.

154 UNIT III Defense

TABLE 8.5 Fungal Infections

Infection Distribution Vector Symptoms

Cryptococcosis Everywhere Pigeon feces Fever, cough, weight loss, pleuritic pain, CNS disturbances Candidiasis Normal flora N/A Mucocutaneous pain and pruritus at site of infection Phycomycosis

(mucormycosis) Everywhere Decayed matter,

soil Rhinocerebral mucormycosis: destruction of CN II, IV, V, VI;

erosion of carotid artery; meningitis; brain abscess Pulmonary mucormycosis: dyspnea, chest pain, hemoptysis

Histoplasmosis River valleys (e.g., California), southwestern USA (Arizona, Nevada)

Bird and bat feces Flulike: cough, fever, myalgias, weight loss, anemia, leukopenia, thrombocytopenia, painful oropharyngeal ulcers

Coccidioidomycosis (San Joaquin Valley fever)

Semiarid USA (e.g., California), southwestern USA (Arizona, Nevada)

Dust, dirt Cough, fever, pleuritic chest pain, weight loss, dyspnea, chest pain, CNS disturbances

Blastomycosis Southeastern USA, south central USA, Midwestern USA, Great Lakes region

Unknown Flulike: pleuritic chest pain, arthralgias, erythema nodosum, weight loss, fever, cough, chest pain

Aspergillosis Everywhere Decaying vegetation Dyspnea, chest pain, hemoptysis, wheezing

CN, Cranial nerve; CNS, central nervous system; GU, genitourinary; N/A, not applicable.

TABLE 8.4 Human Diseases Caused by Specific Viruses

Baltimore Classification Family Virus Disease

dsDNA Adenoviruses Adenovirus Acute febrile pharyngitis Herpes viruses Herpes simplex type 1 (HSV-1) Lesions in mouth, pharynx, conjunctivitis

Herpes simplex type 2 (HSV-2) Sores on labia, meningitis in children Herpes simplex type 8 (HSV-8) Kaposi sarcoma Epstein–Barr virus (EBV) Mononucleosis, Burkitt lymphoma Cytomegalovirus (CMV) Mononucleosis, congenital infection Varicella-zoster virus (VZV) Chickenpox, shingles

ssDNA Papovaviruses Papillomavirus Warts, cervical carcinoma dsRNA Reoviruses Rotavirus Severe diarrhea ssRNA+ Picornaviruses Coxsackievirus Nonspecific febrile illness, conjunctivitis, meningitis

Hepatitis A virus Acute hepatitis Poliovirus Poliomyelitis Rhinovirus Common cold

Flaviviruses Hepatitis C virus Acute or chronic hepatitis, hepatocellular carcinoma Yellow fever virus Yellow fever Dengue virus Dengue fever West Nile virus Meningitis, encephalitis

Togaviruses Rubella virus Acute or congenital rubella Coronaviruses SARS Severe respiratory disease Caliciviruses Norovirus Gastroenteritis

ssRNA− Orthomyxoviruses Influenza virus Influenza Paramyxoviruses Measles virus Measles

Mumps virus Mumps Parainfluenza Croup, pneumonia, common cold Respiratory syncytial virus (RSV) Pneumonia, influenza-like syndrome

Rhabdoviruses Rabies virus Rabies Bunyaviruses Hantavirus Viral hemorrhagic fever Filoviruses Ebola virus Viral hemorrhagic fever

Marburg Viral hemorrhagic fever Arenavirus Lassa virus Viral hemorrhagic fever

ssRNA + with RT Retroviruses HIV AIDS dsDNA with RT Hepadna viruses Hepatitis B virus Acute or chronic hepatitis, hepatocellular carcinoma

AIDS, Acquired immunodeficiency syndrome; DNA, deoxyribonucleic acid; ds, double-stranded; HIV, human immunodeficiency virus; RNA, ribonucleic acid; RT, reverse transcriptase; SARS, severe acute respiratory syndrome; ss single-stranded.

CHAPTER 8 Infectious Processes 155

TABLE 8.6 Parasitic Infections

Parasitic Agent Common Name of Disease

Location of Infection Symptoms Mode of Transmission

Helminths (Worms) Nematodes (Roundworms) Ancylostoma duodenale Hookworm Blood vessels of gut Anemia Skin penetration Ascaris lumbricoides Giant roundworm Small intestine, lungs Pneumonitis (rare), intestinal

obstruction (rare) Oral (fecal contamination),

autoinfection Enterobius vermicularis Pinworm Cecum Anal pruritus Oral Onchocerca volvulus River blindness Skin, eye Blindness Insect inoculation Strongyloides stercoralis Strongyloidiasis Small intestine, lungs Eosinophilia, urticaria, rash, abdominal

pain, pneumonitis Skin penetration, autoinfection

Trichinella spiralis Trichinosis Muscles Muscular pain, eosinophilia, fever, periorbital edema

Oral (infected meat)

Trichuris trichiura Whipworm Intestine Rectal prolapse Oral (fecal contamination) Wuchereria bancrofti Filariasis Lymphatics Elephantiasis Insect (mosquito)

Trematodes (Flukes) Clonorchis sinensis Liver fluke Liver Biliary obstruction (rare) Oral (raw fish) Fasciola hepatica Liver fluke Liver Fever, right upper quadrant abdominal

pain, eosinophilia Oral

Fasciolopsis buski Intestinal fluke Liver Abdominal pain, diarrhea Oral Paragonimus westermani Lung fluke Lung, intestine Eosinophilia, cough, chest pain,

bronchitis Oral (poorly cooked freshwater

crab or crayfish) Schistosoma haematobium Blood fluke Urinary tract Acute: rash, fever, cough, chest pain,

chills Skin inoculation

Schistosoma japonicum Blood fluke Mesenteric blood vessels

Hepatomegaly, splenomegaly Skin inoculation

Schistosoma mansoni Blood fluke Mesenteric blood vessels

Lymphadenopathy, eosinophilia Skin inoculation

Cestodes (Tapeworms) Diphyllobothrium latum Fish tapeworm Intestine Megaloblastic anemia Oral (poorly cooked fish) Taenia saginata Beef tapeworm Intestine Mild abdominal pain Oral (poorly cooked beef) Taenia solium Pork tapeworm Intestine Mild abdominal pain Oral (poorly cooked pork) Echinococcus granulosus Hydatid cyst Lung, liver Cholestasis, liver congestion and

atrophy, biliary obstruction Oral (inoculation with sheep,

cattle, or dog feces)

Protozoa Entamoeba histolytica Amebic dysentery Intestine Bloody, mucoid diarrhea; colicky

abdominal pain Contaminated water, raw

vegetables Plasmodium spp. Malaria Liver, erythrocytes High fever, chills, rigor, anemia,

headache, malaise, chest pain, abdominal pain

Female Anopheles mosquito

Leishmania spp. Kala azar; cutaneous leishmaniasis

Reticuloendothelial cells of body disseminates to spleen, liver, bone marrow, lymph glands

Chronic: abdominal discomfort, ascites, fever, weakness, pallor, weight loss, cough

Acute: sudden fever, chills

All transmission accomplished through bite of sandflies after biting specific infected mammals

Trypanosoma spp. T. cruzi Chagas disease Bloodstream Local inflammation, lymphadenopathy,

muscular necrosis including myocardium (heart failure), esophagus, and colon (dilation); fever, malaise, anorexia, edema of face

Insects—hematophagous Triatoma (blood drinking)

T. brucei African sleeping sickness

Bloodstream Fever, malaise, headache, rash, CNS disturbances

Glossina flies (tsetse flies)

Continued

156 UNIT III Defense

TABLE 8.6 Parasitic Infections—cont’d

Parasitic Agent Common Name of Disease

Location of Infection Symptoms Mode of Transmission

Toxoplasma gondii Toxoplasmosis Throughout body Acute: usually asymptomatic Immunosuppressed: encephalitis,

myocarditis, pneumonitis

Eating raw or undercooked meat, poultry, or dairy foods; oral inoculation with cat feces

Newborn: impaired vision, neurologic disorders

Giardia lamblia Epidemic diarrhea Intestine Acute: self-limited diarrhea; occasionally malabsorption with weight loss

Fecal contamination of water; person to person

Trichomonas vaginalis Trichomoniasis (vaginitis)

Vagina Irritation, discharge Sexually transmitted

Ectoparasites Pediculus humanus Var. corporis Body louse All hair-covered parts of

body Pruritus Nits at base of hair shaft

Person to person, by fomites

Var. capitis Head louse Head area Pediculus pubis Pubic louse Pubic area Sarcoptes scabiei (var.

hominis) Scabies Skin Pruritus, worse at night; linear burrows

in folds of fingers, elbows, knees, axillae, pelvic girdle

Person to person

Maggots (larvae of dipterous flies)

Myiasis Necrotic tissue Depends on location of infestation Dipterous flies

Chiggers (mites) Skin Intense pruritus, hemorrhagic papules Inhabit dogs, rabbits, cats, rats; foul cheese, flour, house dust

Ticks Skin Can transmit tick paralysis, Lyme disease

Reside in wooded and grassy areas

FIG 8.9 Trypanosoma brucei parasite in a blood smear. Giemsa-stained light photomicrograph. (Courtesy Blaine Mathison, Centers for Disease Control and Prevention, Atlanta.)

CHAPTER 8 Infectious Processes 157

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infants. Acta Paediatr 98:229–238, 2009. Collado MC, Bäuerl C, Pérez-Martínez G: Defining microbiota for developing

new probiotics. Microb Ecol Health Dis 23:35–39, 2012. Jacobi CA, Malfertheiner P: Escherichia coli Nissle 1917 (Mutaflor): new

insights into an old probiotic bacterium. Dig Dis 29:600–607, 2011. McCance KL, Huether SE: Pathophysiology: the biologic basis for disease in

adults & children, ed 7, St Louis, MO, 2015, Mosby. Qin J, Li R, Raes J, et al: A human gut microbial gene catalogue established by

metagenomic sequencing. Nature 464:59–65, 2010. Ryan K, Ray CG, Ahmad N, et al: Sherris medical microbiology, ed 6, New

York, 2014, McGraw-Hill. Vallès Y, Gosalbes MJ, de Vries LE, et al: Metagenomics and development

of the gut microbiota in infants. Clin Microbiol Infect 18:21–26, 2012.

WHO: Guideline: Nutritional care and support for patients with tuberculosis. Geneva: World Health Organization; 2013. Available at: http:// apps.who.int/iris/bitstream/10665/94836/1/9789241506410_eng.pdf.

Emerging Infectious Diseases CDC: Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus

Disease. August 1, 2014. Available at: http://emergency.cdc.gov/han/ han00364.asp. (b) WHO. Ebola Situation Report. Update, September 16, 2015. Available at: http://apps.who.int/ebola/sites/default/files/atoms/files// who_ebola_situation_report_16-09-2015.pdf?ua=1.

CDC: Measles cases and outbreaks, February 23, 2015. Available at: http:// www.cdc.gov/measles/cases-outbreaks.html.

CDC: Zika virus, June 14, 2016. Available at: https://www.cdc.gov/zika/ index.html.

Delves PJ, Martin SJ, Burton DR, Roitt IM: Roitt’s essential immunology, ed 12, Boston, 2011, Wiley-Blackwell Publishing.

Riedel S: Biological Warfare and Bioterrorism: A Historical Review. Proc (Bayl Univ Med Cent) 17(4):400–406, 2004.

WHO: Middle East respiratory syndrome coronavirus (MERS-CoV), Update, July 23, 2014: Available at: http://www.who.int/csr/don/2014_07 _23_mers/en/.

The host–microbe relationship is determined by the characteristics of both the microorganism and the host. Many microorganisms are com- mensal and make up the human microbiome that is thought to protect from pathogens. Multiple host factors such as the integrity of barriers to transmission, nutritional status, age, and drug regimen all have an impact on this relationship and may increase the risk of infection with

pathogens. Infection is an important cause of morbidity and mortality in health care facilities. Health care professionals have a key role in the prevention, surveillance, and early detection of infectious processes in hospital and community settings. The identification of high-risk individu- als who are more susceptible to infection will assist in earlier detection and better management to improve outcomes.

S U M M A R Y

158

9

Inflammation and Immunity Jacquelyn L. Banasik

K E Y Q U E S T I O N S • What are the major organs and cellular components of the body’s

defense against foreign antigens? • How do immune cells communicate through cell-to-cell

interactions and through secreted cytokines? • How do innate and adaptive immune mechanisms differ? • How do macrophages, granulocytes, and lymphocytes work

together to locate, recognize, and eliminate pathogens?

• What is the role of MHC class I and II proteins in cell-mediated immunity?

• Why is an immune response usually more effective on subsequent exposure to an antigen than after the first exposure?

• How do noncellular immune system components, including antibodies, complement, and clotting factors, aid the immune response?

C H A P T E R O U T L I N E COMPONENTS OF THE IMMUNE SYSTEM, 159 Epithelial Barriers, 159 Mononuclear Phagocyte System, 159 Lymphoid System, 160

Primary Lymphoid Organs, 160

Secondary Lymphoid Organs, 161

Tonsils, 161 Spleen, 161 Lymph Nodes and Lymphatics, 161 Peyer Patches, 162

Leukocytes, 162 Neutrophils, 162

Eosinophils, 163

Basophils and Mast Cells, 164

Monocytes and Macrophages, 164

Dendritic Cells, 165

Lymphocytes, 165

Natural Killer Cells, 166 T Lymphocytes, 166 B Lymphocytes, 167

Chemical Mediators of Immune Function, 167 Complement, 167

Kinins, 169

Clotting Factors, 169

Cytokines and Chemokines, 169

INNATE DEFENSES AND INFLAMMATION, 169 Inflammation, 171

Increased Vascular Permeability, 171

Emigration of Leukocytes, 172

Phagocytosis, 172

Chronic Inflammation, 174

Healing, 174 Inflammatory Exudates, 175 Systemic Manifestations of Inflammation, 175 SPECIFIC ADAPTIVE IMMUNITY, 176 Major Histocompatibility Complex, 176 Antigen Presentation by MHC, 176

MHC Class I Presentation, 177

MHC Class II Presentation, 177

Mechanisms of Cell-Mediated Immunity, 178 T Helper Cells (CD4+), 178

Cytotoxic T Cells (CD8+), 181

Mechanisms of Humoral Immunity, 181 Antigen Recognition by B Cells, 181

Antibody Structure, 183

Class Switching and Affinity Maturation, 185

Antibody Functions, 186

Passive and Active Immunity, 187 Passive Immunity, 187

Active Immunity, 187

INTEGRATED FUNCTION AND REGULATION OF THE IMMUNE SYSTEM, 189

Integrated Response to Microbial Antigen, 189 Integrated Response to Viral Antigen, 191 Regulation of Immune Function, 192

http://evolve.elsevier.com/Banasik/pathophysiology/ • Review Questions and Answers • Glossary (with audio pronunciations for selected terms) • Animations

• Case Studies • Key Points Review

CHAPTER 9 Inflammation and Immunity 159

of bactericidal peptide called cryptocidins that prevent bacteria from colonizing the intestinal wall. Resident microorganisms may aid in providing this line of defense by making conditions inhospitable for pathogens (see Chapter 8). Disruption of the normal epithelial barriers increases the likelihood that pathogens will successfully establish an infection. Physical trauma (e.g., burns, lacerations, erosions) and biochemical alterations (e.g., pH changes, increased glucose concentra- tion, decreased enzyme production) predispose to infection. Pathogens that breach the skin or mucous membranes are generally first detected by cells of the mononuclear phagocyte system. These cells are thought to originate from monocytes produced in the bone marrow. Specialized antibody-secreting cells also locate to the mucous membranes where they produce antibodies of the immunoglobulin A (IgA) class. IgA antibodies bind antigens on the mucosal surface and prevent them from entering more deeply into the tissues.

MONONUCLEAR PHAGOCYTE SYSTEM The mononuclear phagocyte system (previously called the reticuloen- dothelial system) is composed of dendritic cells, monocytes, and macrophages that are widely distributed throughout the body. Monocytes from the circulating blood migrate to organs and tissues to become macrophages. Macrophages are found throughout the body and are assigned various names according to the tissues in which they are located, such as alveolar macrophages in the lungs, microglial cells in the brain, Kupffer cells in the liver, and histiocytes in connective tissue (Fig. 9.1). Tissue dendritic cells are a monocyte-derived cell type that specializes in capturing and presenting antigens to T cells. Dendritic cells are strategically located in subcutaneous and submucosal tissues.

Macrophages and dendritic cells are often the first immune system cells to encounter a pathogen or foreign antigen after it has entered the

The immune system is a complex network of cells and tissues that work together to protect the body against foreign invaders. The wide variety of potential pathogens requires a defense system that is diversified and adaptable. Several types of white blood cells (WBCs) are important in localizing, recognizing, and eliminating foreign substances. These immune cells are strategically situated in diverse locations so that pathogens may be detected quickly. The dispersed nature of these defensive cells necessitates a complex system of intercellular communication to effectively mobilize reinforcements to areas of need. A tremendous amount of information has accumulated about how immune cells communicate and the processes that enable them to migrate to particular locations. The impact of this research goes far beyond the traditional immune disorders such as immunodeficiency diseases and hypersensitiv- ity reactions. The immune system has been implicated in the pathogenesis of disorders as diverse as atherosclerosis, myocardial infarction, shock, diabetes, and stroke. Therefore an understanding of immune function is fundamental to the study of a wide variety of diseases. This chapter describes the organs and cells that constitute the immune system, the mechanisms of action of innate and adaptive defenses, and the com- munication processes whereby immune cells achieve a coordinated response. Underreactions and overreactions of the immune system, immune system malignancies, and human immunodeficiency virus disease are described in Chapters 10, 11, and 12, respectively.

COMPONENTS OF THE IMMUNE SYSTEM The structures of the immune system include (1) skin and mucous membranes; (2) the mononuclear phagocyte system; (3) the lymphoid system, including spleen, thymus gland, and lymph nodes; and (4) bone marrow. All these structures are inhabited by different types of WBCs (leukocytes) that mediate inflammation and immunity. Leukocytes are responsible for locating and eliminating pathogens and foreign molecules. They are aided in their task of bodily defense by a number of chemical mediators, including complement, kinins, clotting factors, cytokines, and chemokines.

Components of the immune system are often categorized into specific or innate defenses according to the mechanisms whereby antigens are recognized. Innate defenses require no previous exposure to mount an effective response against an antigen, and a wide variety of different antigens are recognized. Natural killer (NK) cells and phagocytic cells such as neutrophils and macrophages are mediators of innate defenses. In contrast, specific defenses respond more effectively on second exposure to an antigen (adaptive) and are highly selective in the ability to recognize antigens. B lymphocytes (B cells) and T lymphocytes (T cells) are the agents of specific immunity.

Although separating immune components into specific and innate systems is helpful for studying inflammation and immunity, it is an artificial division because they function in a highly integrated manner. The approach used in this chapter is to first describe the major com- ponents of the immune system, discuss innate and specific adaptive defenses separately, and then summarize the integrated function of the entire system and its regulation.

EPITHELIAL BARRIERS The skin and mucous membranes are sometimes called the “first line of defense” because they are frequently the initial sites of microbial invasion. Intact epithelia in skin and mucous membranes provide mechanical and chemical barriers that prevent microorganisms from gaining access to the body’s tissues. The skin epithelium produces antimicrobial peptides called defensins that can kill a wide variety of bacteria and fungi. The intestinal epithelium produces another form FIG 9.1 Cells of the mononuclear phagocyte system.

160 UNIT III Defense

9.2). T lymphocytes then migrate to the thymus for development, whereas B lymphocytes and NK cells stay in the marrow to develop. NK cells are a population of lymphocytes that lack both T-cell and B-cell markers. NK cells are produced and released from the bone marrow and function in innate immune responses. NK cells are found mainly in the circulation and spleen. Once mature, T and B lymphocytes migrate to the secondary lymphoid organs where they await activation by antigens. Secondary lymphoid organs include the tonsils, spleen, lymph nodes, and Peyer patches (Fig. 9.3).

Primary Lymphoid Organs Bone marrow is contained in all the bones of the body. The primary function of bone marrow is hematopoiesis, or the formation of blood cells. There are two kinds of bone marrow: red and yellow. Hematopoiesis is carried out by red (functioning) marrow. By adulthood, red marrow is confined to the pelvis, sternum, ribs, cranium, ends of the long bones, and vertebral spine. Yellow or fatty bone marrow is found in the remaining bones. It normally does not contribute to hematopoiesis in adults, but

body, and they are instrumental in communicating news of the invasion to other immune cells. This communication is accomplished through secretion of chemical signaling molecules called cytokines and by presenta- tion of captured antigen to the specific, adaptive immune cells. Dendritic cells specialize in antigen presentation and are able to migrate quickly to lymphoid tissues when they have captured antigens. Macrophages have many other roles in the immune response in addition to their sentry function. Macrophages are powerful phagocytes, each capable of ingesting numerous microbes. Macrophages are called on to clean up the area in which dead neutrophils and inflammatory debris have accumulated after an inflammatory reaction, and they have a role in wound healing.

LYMPHOID SYSTEM The primary lymphoid organs are the bone marrow and thymus gland, which are the structures where lymphocytes develop. All types of lymphocytes are produced from stem cells in the bone marrow (Fig.

PERIPHERAL BLOODSTREAM

BONE MARROW

Embryonic liver and spleen– site of extramedullary

hematopoiesis

Bone marrow–site of medullary hematopoiesis in fetus, newborn, infant,

and adult

Pluripotential stem cell

Monoblast Pre B cell

Lymphoid stem cell (thymus)

Prothymocyte

Promonocyte

Monocytes BasophilEosinophil

Granulocytes

Neutrophil

Basophilic metamyelocyte

Eosinophilic metamyelocyte

Neutrophilic metamyelocyte

Basophilic myelocyte

Eosinophilic myelocyte

Promyelocyte

Myeloblast

Platelet-producing megakaryocyte

Basophilic megakaryocyte

Granular megakaryocyte

Megakaryoblast

Neutrophilic myelocyte

Immature (band)

neutrophil

Thrombocytes (platelets)

Macrophage

Leukocytes (white cells)PlateletsRed cells

Erythrocytes (red cells)

Reticulocyte

Acidophilic erythroblasts

Polychromatophilic erythroblasts

Basophilic erythroblast

Erythroblast

Mast cell Plasma cell

T lymphoblast Natural killer cells

B lymphoblast

B cell (lymphocyte)

T cell (lymphocyte)

Myeloid stem cell

FIG 9.2 Maturation of human blood cells showing pathways of cell differentiation from the pluripotent stem cell to mature granulocytes, monocytes, lymphocytes, thrombocytes, and erythrocytes. Production begins in embryo blood islands in the yolk sac. As the embryo matures, production shifts to the liver, spleen, and bone marrow. In an adult, nearly all hematopoiesis occurs in the bone marrow. The two major differentiation pathways are the myeloid pathway and the lymphoid pathway. The lymphoid pathway produces lymphocytes, whereas the myeloid pathway produces granulocytes, monocytes, platelets, and red blood cells.

CHAPTER 9 Inflammation and Immunity 161

tissues, including lymph nodes, spleen, tonsils, and Peyer patches in the intestine. These naive T cells and B cells express specific chemokine receptor proteins on their cell surfaces that allow them to migrate, or “home,” to specific locations in lymph tissue. Most mature T lymphocytes are in constant circulation through lymphatic tissues and the bloodstream. It has been estimated that a lymphocyte makes a circuit from the blood to tissues to lymphatics and back to the bloodstream once or twice per day. Antigens can be carried to the naive cells in the lymph nodes by the specialized antigen-presenting dendritic cells. When exposed to an appropriate antigen, T cells and B cells migrate toward each other within the lymph nodes and begin to proliferate. Activated T cells may then migrate to lymph vessels and travel to the bloodstream, where they are dispersed throughout the system. The majority of B cells stay in the lymph node, where they mature into antibody-secreting plasma cells. Lymphocyte recirculation and homing are regulated by binding interac- tions between various types of cell adhesion molecules, including selectins, integrins, chemokines, and addressins.

Tonsils Tonsils are aggregates of lymphoid tissue located in the mouth and pharynx. The tonsils are strategically located at the entrance to the digestive and respiratory tracts, where they are likely to encounter microorganisms. Unlike lymph nodes, tonsils have no afferent (incoming) lymphatic vessels. They do have efferent lymphatic drainage so that activated lymphocytes from the tonsils can migrate to other lymphoid organs. Tonsils normally make an important contribution to immune function; however, they may occasionally become chronically infected, and surgical removal (tonsillectomy) is then helpful.

Spleen The spleen is located under the diaphragm on the left side of the body. It measures about 12 cm in length, which makes it the largest of the lymphoid organs. The spleen provides an important filtering function for blood. The tissue structure of the spleen is similar to that of lymph nodes. It is surrounded by a capsule of connective tissue and filled with a meshwork of red pulp and localized masses of lymphocytes called white pulp. Within the red pulp are many blood-filled sinuses lined with macrophages. Macrophages filter out foreign substances and old red blood cells. Lymphocytes located in the white pulp are in a strategic position to come into contact with bloodborne antigens. Lymphocytes thus activated in the spleen can migrate to other lymphoid organs via efferent lymphatics. Like the tonsils, the spleen does not have afferent lymphatic vessels.

Lymph Nodes and Lymphatics The lymphatic vessels begin with small, closed-ended lymphatic capillaries in direct contact with the interstitial fluid surrounding cells and tissues. Lymphatics pick up fluid and proteins that escape the bloodstream and return them to the circulation by way of the right lymphatic and thoracic ducts. Along the way from lymphatic capillaries to the thoracic ducts, lymph flows through specialized structures called lymph nodes. Lymph nodes are found primarily in the neck, axilla, thorax, abdomen, and groin. They often become tender and palpable when responding to foreign invaders. Projections of connective tissue called trabeculae divide the interior of the lymph node into compartments (Fig. 9.4). Lymph nodes contain large numbers of B and T lymphocytes and macrophages. B cells are the predominant cell type in the cortical follicles, whereas T cells predominate in the area just under the cortex called the parafol- licular. The central region, or medulla, is populated by macrophages, B cells, and plasma cells (antibody-secreting B cells). Lymph fluid flows through the nodes in a way that allows these immune cells to filter, detect, and react to foreign material.

can be recruited to become red marrow again under conditions of increased need for hematopoiesis.

B cells are produced and develop in the bone marrow. B cells migrate from the outer edges toward the center of the bone marrow as they develop. Pre–B cells are subjected to a highly selective quality control process, and less than 25% of the developing B cells are allowed to survive. During migration through the bone marrow, immature B cells are exposed to self antigens. B cells that do not bind to self antigens continue to develop into mature B cells. If immature B cells encounter self antigens to which they bind while still in the bone marrow, a series of events is triggered to induce self-tolerance. The immature B cell is stimulated to reactivate its genetic recombination machinery in an attempt to produce a new B-cell receptor (BCR) that does not bind to self antigens. If this receptor-editing attempt fails to alter binding sufficiently, the immature B cell will undergo apoptosis in the bone marrow. Mature B cells that leave the bone marrow to colonize secondary lymphoid organs are called naive B cells because they have not yet encountered antigen.

T cells develop in the thymus, which is located in the anterior mediastinum overlying the heart. Pre–T cells initially enter the outer aspect (cortex) of the thymus lobules, and many die while they migrate to the center (medulla) of the thymus. The selection process for T cells is even more rigorous than that for B cells; only about 5% of the cells entering the thymus survive to reenter the circulation and colonize secondary lymphoid organs. The thymus is relatively large at birth and steadily atrophies after puberty. The thymus produces interleukin-7 (IL-7), a cytokine that promotes T-cell proliferation.

Secondary Lymphoid Organs Once mature, lymphocytes leave their primary lymphoid organs and travel through the blood to localize in peripheral, or secondary, lymphoid

Tonsils and adenoids

Lymph nodes

Spleen

Appendix

Peyer patches in intestinal wall

Lymphatic vessels

Thymus gland

Bone marrow

FIG 9.3 Principal organs of the lymphoid system.

162 UNIT III Defense

neutrophils, eosinophils, and basophils. Basophils are precursors of the mast cells located in tissues.

Development of these cell types is influenced by hormonal signaling molecules called cytokines. Cytokines are produced locally in the bone marrow and by various other cells. Certain cytokines stimulate stem cell growth, proliferation, and differentiation into particular cell types. The WBC count and differential are commonly measured laboratory tests used to evaluate WBC production. A normal WBC count and differential are shown in Table 9.1. The general features of each of the WBC types are summarized in the following sections.

Neutrophils Neutrophils are circulating granulocytes that are also known as poly- morphonuclear leukocytes (polys or PMNs). They account for 60% to 80% of the total WBC count. Neutrophils normally have two to five nuclear lobes and coarse, clumped chromatin. Neutrophils arise from bone marrow stem cells and undergo several stages of maturation. As illustrated in Fig. 9.2, these stages, from least to most mature, are myeloblast, promyelocyte, metamyelocyte, band cell, and mature seg- mented neutrophil.

Neutrophils stored in the bone marrow outnumber, by about tenfold, the quantity of circulating neutrophils. An adult produces more than 1 × 1011 neutrophils each day. These stored neutrophils are released into the circulation, where they have a half-life of 4 to 10 hours. Neutrophils that are not recruited into tissues within about 6 hours undergo programmed

Peyer Patches Aggregates of lymphoid tissue can be found scattered throughout the body, particularly in the gastrointestinal, respiratory, and urogenital tracts. These structures are analogous to lymph nodes, but they are not encapsulated and contain primarily B cells. Because of their location, these structures have been termed mucosa-associated lymphoid tissue or gut-associated lymphoid tissue. These structures, also called Peyer patches, are of particular importance in producing antibodies to microorganisms that tend to invade mucosal tissue.

LEUKOCYTES Leukocytes, or WBCs, are the primary effector cells of the immune system. Each of the different types of leukocytes found in blood has a special job to perform. All leukocytes, as well as red blood cells and platelets, are formed from stem cells in the bone marrow. Stem cells can produce daughter cells that differentiate along several different pathways to become mature cell types (see Fig. 9.2). The first major differentiation step produces either a lymphoid stem cell or a myeloid stem cell. Lymphoid stem cells further differentiate to form B and T lymphocytes and NK cells. Myeloid stem cells can produce a variety of cell types, including red blood cells, platelets, monocytes, dendritic cells, and granulocytes. Monocytes that migrate from the blood into tissues are called macrophages. Granulocytes are further divided into

Capsule

Efferent lymph vessel

Medulla

Cortex (follicle) (B-cell zone)

Germinal centers

Trabecula

Afferent lymph vessel

Parafollicular (T-cell zone)

FIG 9.4 Schematic drawing of a typical lymph node showing afferent and efferent lymph vessels, as well as B-cell and T-cell zones.

CHAPTER 9 Inflammation and Immunity 163

Initially during an acute infection, neutrophilia, or an increase in the number of circulating neutrophils, occurs as the bone marrow releases stored neutrophils. As neutrophils are consumed and demand exceeds production, an increase in the number of immature (band) neutrophils occurs. Bands are identified by their lack of nuclear segmenta- tion. This increase in band cells is referred to as a “shift to the left of normal” (Fig. 9.5). Traditionally, the band count has been used to differentiate bacterial from viral infections, and a greater shift to the left is viewed as a more severe infection.

Neutrophils produce potent chemical mediators that enable them to destroy microorganisms. Numerous toxins released by neutrophils have been identified, including oxidizing free radicals, defensins, and proteolytic enzymes, such as elastase. Because of the ability to generate free radicals and release enzymes, neutrophils can cause extensive damage to normal tissue during their inflammatory response.

Eosinophils Eosinophils are circulating granulocytes that have two nuclear lobes and stain brilliant red-orange with eosin. They constitute 1% to 6% of the total WBC count. Eosinophils mature in the bone marrow (3 to 6 days) and circulate in the blood for about 30 minutes. They have a half-life of 12 days in tissue. Eosinophils arise from myeloid stem cells and undergo a maturation process similar to that of neutrophils.

Eosinophils are particularly associated with an increase in number during allergic reactions and infection by intestinal parasites. The role of eosinophils in allergic reactions is less well characterized than that of mast cells. Eosinophils are recruited into areas of inflammation by the chemokine eotaxin, which is produced by epithelial cells. Eosinophils release inflammatory chemicals, such as lysosomal enzymes, peroxidase,

cell death (apoptosis). Neutrophils are early responders to an acute bacterial infection and arrive in large numbers very quickly. They are phagocytes that engulf and degrade microorganisms. Circulating neutrophils have receptors on their cell surfaces that enable them to bind to endothelial cells in areas of inflammation. These receptors, called L-selectins, and chemokine receptors allow neutrophils to adhere and roll along the capillary surface. Other interactions between neutrophil integrin receptors and extracellular matrix then facilitate movement of neutrophils through the capillary wall and into the tissue. Neutrophils are attracted to areas of inflammation and bacterial products by chemotactic factors such as complement fragments and cytokines. This process is discussed in more depth in the section titled “Inflammation.”

Immature (band) neutrophil

"Shift to left"

85% Mature 15% Bands

Normal 95% Mature 5% Bands

Myeloid stem cell

Mature neutrophil

Acute infection

FIG 9.5 Inflammatory cytokines stimulate the release of more immature neutrophils, called bands, from the bone marrow. An increased ratio of bands to mature neutrophils is termed a “shift to the left.” This clinical term evolved from the practice of listing bands to the left of mature cells on the laboratory report sheet. A shift to the left is commonly seen with acute bacterial infections.

TABLE 9.1 Leukocyte Proportions and Functions

Type Percentage* Role in Inflammation

Neutrophils 60–80 First to appear after injury, phagocytosis

Lymphocytes 20–30 Immune response Monocytes (macrophages) 3–8 Phagocytosis Eosinophils 1–6 Allergic reactions, parasite

infection Basophils 0–2 Contain histamine, mediate

type I allergic reactions, initiate inflammation

*Total white cell count, 4000 to 10,000/µL.

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(Fig. 9.8). Macrophages are capable of cell division and may proliferate at the site of inflammation.

Macrophages are covered with a variety of receptor proteins on their cell surface (Fig. 9.9). Some of these receptors help macrophages locate antigens that have been coated by antibodies. These receptors are called Fc receptors because they bind to the part of an antibody called the constant fragment, or Fc. Macrophages also have receptors for the complement component C3b. Complement, like antibodies, can coat an antigen and make it more recognizable to macrophages. Coating of antigen by antibodies or by complement is called opsonization. Mac- rophages have receptors that help them recognize bacteria directly. These innate pattern-recognition receptors bind to particular molecules prevalent in the bacterial cell wall. For example, mannose receptors and numerous toll-like receptors on macrophages allow them to recognize

major basic protein, and cationic protein. The primary function of eosinophils is to kill parasitic helminths (worms). Helminths are too large to be phagocytosed by neutrophils or macrophages, and their exterior is resistant to attack by complement or mast cell products. Eosinophils produce specialized molecules such as major basic protein and eosinophil cationic protein, which may be more effective against helminths (Fig. 9.6). Eosinophils recognize helminths that have been opsonized (coated) with IgE antibody. They bind to the IgE and then release their stored chemicals onto the surface of the opsonized helminth. Parasitic infections are a significant problem in much of the world, with one-third of the population being affected.

Basophils and Mast Cells Basophils are granulocytes characterized by granules that stain blue with basophilic dyes. Basophils account for 0% to 2% of the total leukocyte count. Basophils are structurally similar to mast cells. Mature basophils circulate in the vascular system, whereas mast cells are found in connective tissue, especially around blood vessels and under mucosal surfaces. When stimulated by cytokines, mature basophils can migrate to connective tissue, but once in the tissue, basophils (then called mast cells) do not reenter the circulation.

The average basophil life span is measured in days, whereas mast cells can live for weeks to months. Mast cells and basophils have IgE receptors that allow them to bind and display IgE antibodies on their cell surfaces. When an appropriate stimulus occurs, such as antigen binding to the IgE antibodies, mast cells and basophils release granules (degranulate) containing proinflammatory chemicals.

Mast cell and basophil granules contain histamine, platelet-activating factor, and other vasoactive amines that are important mediators of immediate hypersensitivity responses (Fig. 9.7). Degranulation of mast cells and basophils begins the inflammatory response that is characteristi- cally associated with allergic reactions. Mast cells and basophils are also involved in wound healing and chronic inflammatory conditions (see Chapter 10).

Monocytes and Macrophages Monocytes and macrophages, like granulocytes, originate from bone marrow stem cells of the myeloid lineage. Monocytes are immature macrophages and account for about 5% of the total WBC count. Monocytes circulate in the bloodstream for about 3 days before they enter tissue to become macrophages. As described earlier, macrophages are found in widespread locations as part of the mononuclear phagocyte system.

Phagocytosis by macrophages is similar to that by neutrophils except that neutrophils are short-lived and die in the process of fighting infec- tion. Macrophages, in contrast, may live for months to years and can migrate in and out of tissue. Macrophages are more efficient phagocytes than neutrophils and can ingest several times as many microorganisms

FIG 9.6 Small dots are eosinophils migrating toward and attacking the worm over time. (From Patnode ML, Bando JK, Krummel MF, et al: Leukotriene B4 amplifies eosinophil accumulation in response to nema- todes. J Exp Med 211(7):1281-8, 2014.

FIG 9.7 Micrograph of a mast cell showing a large yellow nucleus and numerous packets containing histamine, which are colored red. (From Roitt IM, Brostoff Male DK: Immunology, ed 3, St Louis, 1993, Mosby.)

FIG 9.8 Scanning electron micrograph of a macrophage (red) attaching to and phagocytizing bacteria (yellow). (From Nairn R, Helbert M: Immunology for medical students, ed 2, St Louis, 2007, Mosby, p 3. With permission from Juergen Berger, Max-Planck Institute, and the Science Photo Library.)

CHAPTER 9 Inflammation and Immunity 165

common microbial structures (see Fig. 9.9). Other receptors, called selectins, chemokine receptors, and integrins help macrophages adhere to capillary walls and enter and move through tissue. Integrin receptors bind to proteins in the extracellular matrix and help macrophages target, or “home,” to certain areas.

In addition to their phagocytic function, macrophages have an important secretory function. Some of the substances secreted by macrophages are cytokines, which help coordinate the activities of other immune cells (Fig. 9.10). Macrophage cytokines include IL-1, IL-6, IL-12, and tumor necrosis factor-α (TNF-α). These cytokines promote inflammation, as well as the activity of other WBCs, including neutrophils and lymphocytes (see the section titled “Cytokines and Chemokines”).

Macrophages secrete a number of proteins that are important in wound healing. Some of these proteins are enzymes that degrade tissue (e.g., collagenase, elastase, plasminogen activator), whereas others stimulate the growth of new granulation tissue (e.g., fibroblast growth factor, angiogenic factors).

A third function of macrophages, in addition to phagocytosis and secretion, is antigen presentation. For T cells to recognize antigens, these antigens must first be processed and presented on the surface of an antigen-presenting cell such as dendritic cells, macrophages, or B cells. Macrophages accomplish this task by first engulfing the antigen, then processing it into smaller pieces, and finally combining the antigen fragments with special membrane proteins. The antigen complexes are then displayed on the macrophage cell surface, where T lymphocytes (T helper cells) can recognize and become activated by them. Antigen presentation is explored in more detail in the section titled “Specific Adaptive Immunity.”

Cytokine receptors

Selectin and integrin receptorsComplement

receptors

Antibody receptors

Fc IL-2

CD62 CD11/18CR1

CR3

CD14

Microbe

Microbe

Microbe

Toll-like receptors

LPS IgG

C3b

IL-2

IFN-γ

Endothelium

IFN-γ

FIG 9.9 Macrophage surface receptors. Macrophages display receptors for a number of extracellular molecules that enhance their function such as cytokines, complement, selectins, integrins, and antibody (Fc). Toll-like receptors recognize patterns of microbial components and trigger intracellular signaling cascades in the macrophage. IFN-γ, Interferon-γ; IL, interleukin; LPS, lipopolysaccharide.

Dendritic Cells Dendritic cells are derived in the bone marrow from the same progenitor cells that produce monocytes and macrophages and are structurally and functionally similar to macrophages. Dendritic cells derive their name from an unusual shape that has extensive projections from the surface (Fig. 9.11). Dendritic cells are located throughout the body as part of the mononuclear phagocyte system. They function primarily as antigen-presenting cells, capturing antigen in tissues and then migrat- ing to lymphoid areas to present antigen to T cells. Some types of dendritic cells produce chemical messengers called type I interferon (IFN-α and IFN-β) in response to viral infections. Type I interferons suppress the viral replication machinery in nearby cells and help stop the local spread of the virus.

Lymphocytes The three major types of lymphocytes are NK cells, T cells, and B cells. NK cells function in innate immunity, whereas B and T lymphocytes are the cells responsible for specific, adaptive immunity. B and T cells have the capacity to proliferate into “memory cells,” which provide long-lasting immunity against specific antigens. NK, T, and B cells are derived from a common lymphoid stem cell in the bone marrow that is stimulated to proliferate by bone marrow–derived cytokines, including IL-7. T cells then migrate to the thymus, where they mature. B cells remain in the bone marrow during their maturation phase. NK cells are released into the circulation. Together NK, B, and T lymphocytes compose approximately 20% of the total WBC count. Mature NK cells circulate and populate the spleen, whereas T and B cells migrate to secondary lymphoid organs.

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recognize antibody-coated target cells with their Fc receptors. This process is called antibody-dependent cell-mediated cytotoxicity. NK cells also target virally infected cells and tumor cells. They are thought to be able to recognize virally infected cells through innate pattern- recognition receptors; however, only those cells that lack certain normal self proteins on their cell surface (major histocompatibility complex I, or MHC I, proteins) are targeted for killing. Cells that display normal MHC I on their cell surfaces are protected from NK cell cytotoxicity, but will be susceptible to killing by cytotoxic T cells that recognize viral antigen displayed on the MHC I proteins.

T Lymphocytes Two major classes of T lymphocytes can be differentiated by the presence or absence of CD4 and CD8 surface proteins (Fig. 9.12). T cells that possess CD4 proteins (CD4+) are called T helper cells. T helper cells interact with antigens presented on the surface of specialized antigen- presenting cells such as dendritic cells, macrophages, and B cells. T

Structurally, lymphocytes are small, round cells with a large, round nucleus. Despite their relatively uniform appearance, lymphocytes can be sorted into a number of subpopulations based on characteristic surface proteins called cluster of differentiation (CD) markers. More than 350 different CD markers have been identified thus far, with different immune cell types displaying different combinations on their cell surfaces. Lymphocytes have many complex and differentiated functions, and only the major lymphocyte subtypes are discussed in this chapter.

Natural Killer Cells NK cells have no B- or T-cell markers and are not dependent on the thymus for development. NK cells are considered innate immune cells because they can effectively kill tumor cells and virally infected cells without previous exposure. NK cells kill their target cells by a mechanism similar to that used by cytotoxic T cells. Unlike T and B cells, NK cells can respond to a variety of antigens and are therefore not specific for a particular antigen. Like neutrophils and macrophages, NK cells

Colony- stimulating

factors promote hematopoiesis

Interleukin-12 stimulates

helper T cells and NK cells

Tumor necrosis factor-α

promotes inflammation

Interleukin-1 promotes inflammation

Interleukin-6 stimulates

B-cell growth and inflammation

Interleukin-10 promotes

expression of antigen-presenting proteins (MHC II)

Interleukin-15 and interleukin-18

promote proliferation of NK cells

Fibroblast growth factor

stimulates wound healing

FIG 9.10 Macrophages are of central importance in initiating inflammation and recruitment of other leukocytes to areas of need. Macrophages secrete a variety of cytokines that induce inflammation and chemotaxis. Some macrophage cytokines stimulate the growth and differentiation of other white blood cell types.

A B

FIG 9.11 Dendritic cell morphology. A, Light micrograph of resting dendritic cells from the bone marrow. B, Scanning electron micrograph of a mature dendritic cell showing extensive projections of the cell membrane. (From Abbas AK et al: Cellular and molecular immunology, ed 8, Philadelphia, 2015, Saunders, p 112. Courtesy of Dr. Y-J Liu, MD, Anderson Cancer Center, Houston, TX.)

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to the B cell by physical cell-to-cell contact through coreceptor binding, as well as through secreted cytokines. Some B cells can respond to nonprotein antigens such as bacterial carbohydrate and lipid molecules. B-cell responses to nonprotein antigens are T-cell independent because T cells respond only to peptide antigens. Exposure to antigens stimulates B cells to mature into antibody-secreting plasma cells and memory cells. B-cell memory cells form a reserve of cells that can quickly mount an immune response on subsequent exposure to the same antigen. Memory cells are able to survive for months to years, whereas most antibody-secreting plasma cells live for only a few days. Plasma cells are able to secrete antibodies at a rate of about 2000 per second per cell. Memory B cells and plasma cells develop in germinal centers located in secondary lymphoid organs, including the lymph nodes and spleen. A few long-lived plasma cells inhabit the bone marrow and continue to produce a low level of antibody, which provides immediate protection on second exposure to the same antigen. The mechanisms of specific adaptive immunity are explored later in the chapter.

CHEMICAL MEDIATORS OF IMMUNE FUNCTION Complement The complement system consists of about 30 plasma proteins that interact to enhance inflammation, chemotaxis, and lysis of target cells. Complement proteins are synthesized in the liver and by macrophages and neutrophils. They circulate in the blood in an inactive form. Activa- tion of the complement cascade occurs via three different pathways: classical, alternative, and lectin. In all three pathways, the inactive complement proteins are converted to their active form in a sequence

helper cells can be further divided into subclasses based on the types of cytokines that they secrete. These subtypes are described in the section “Mechanisms of Cell-Mediated Immunity.”

The presence of CD8 protein (CD8+) on a T lymphocyte characterizes it as a cytotoxic T cell. Cytotoxic T cells recognize antigen presented in association with surface proteins that can be found on all nucleated cells of the body (MHC I). When a CD8+ T cell recognizes a foreign antigen on a cell, the antigen-presenting cell is killed, thus the name cytotoxic T cell. CD8+ cells are particularly effective at destroying virally infected cells, foreign cells, and mutant cells (Fig. 9.13). Proliferation of activated cytotoxic T cells is enhanced by T helper cell cytokines, particularly IL-2.

B Lymphocytes B cells are distinguished from other lymphocytes by their ability to produce antibodies and by the presence of antibody-like receptors (BCRs) on their cell surfaces. Each B cell carries many copies of identical BCRs and is able to respond to one specific antigen epitope (Fig. 9.14). Naïve B cells require “help” from T helper cells to respond efficiently to protein antigens. B cells bind and internalize the protein antigen and then process and present it to T helper cells. T cells that recognize the presented peptides bind to and are activated by the B cell. T-cell help is provided

T cell

CD8+CD4+

Helper Cytotoxic

FIG 9.12 Two major classes of T lymphocytes can be differentiated by CD markers on the cell surface. T helper cells have CD4 markers, whereas cytotoxic T cells have CD8 markers.

FIG 9.13 Scanning electron micrograph of activated T cells (blue) and a tumor cell (red). (From Nairn R, Helbert M: Immunology for medical students, ed 2, St Louis, 2007, Mosby, p 3. With permission from BSIP Lecaque and the Science Photo Library.)

Antigen

Epitope

BCR

FIG 9.14 Typical B cell showing a number of identical B-cell receptors (BCRs) on the cell surface. Each BCR is capable of binding to two identical antigen epitopes.

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exposure to an antigen. Lipopolysaccharide, in bacterial cell walls, and bacterial endotoxin are effective triggers of the alternative pathway. In the classical pathway, an antibody hooked onto an antigen combines with C1, the first of the complement proteins. This step sets in motion a domino effect called the complement cascade (Fig. 9.16). The alternative pathway begins with the activation of C3. The alternative pathway can be activated on first exposure and is part of the innate immune response. The lectin pathway also can be triggered on first exposure. Lectin is a circulating biomolecule that binds mannose on bacterial cell walls and triggers complement activation at C2 and C4. C3 spontaneously degrades into active C3b fragments in plasma. If microbial cell surfaces are present, the C3b fragment can bind directly to the microbe. Two other comple- ment proteins, factors B and D, combine with C3b to initiate the alternative pathway. C3 is the most important and plentiful of the complement proteins. C3 divides into two fragments called C3a and C3b. C3a is a proinflammatory protein that causes histamine release from mast cells, contraction of smooth muscle, and increased endothelial cell permeability. C3b initiates the next step in the cascade by cleaving C5 into its active fragments: C5a and C5b. Complement protein fragment C5a is both a powerful inflammatory chemical and a potent chemotactic agent. C5a chemotaxis stimulates neutrophils and monocytes to migrate to the inflamed tissue. C5a also activates neutrophils by triggering their oxidative activity and increasing their glucose uptake.

The C5b fragment combines with C6, C7, C8, and multiple units of C9 to form a large porelike structure (C5b6789) called the membrane

of reactions. Major actions of complement proteins include cell lysis, facilitation of phagocytosis by opsonization, inflammation, and che- motaxis (Fig. 9.15).

The classical pathway is usually triggered by IgG or IgM antibody– antigen complexes. The alternative pathway can be initiated on first

Opsonization (C3b)

Chemotaxis (C5b67)

Anaphylatoxins (bronchospasm)

(C3a)

Recruitment and activation of neutrophils

(C5a) Increased vascular

permeability (C2a,C5a)

Cell lysis (MAC)

Mast cell degranulation

(C3a)

COMPLEMENT ACTIVATION

FIG 9.15 Activation of the complement cascade results in the production of products that perform a variety of functions to augment the immune response. MAC, Membrane attack complex.

C1

C4 Enzyme

Classical pathway

Alternative pathway

Antigen

C3b C5b

C6 C8

Membrane attack complex

C7

C9

C5b

C5a

C2

IgG

C3

C3a

C5

Water

Water

Cell lysis

Na+

Na+ Na+

Na+ Na+

Target cell

FIG 9.16 Complement cascade. The cascade is activated by the first complement molecule, C1, that binds an antigen–antibody complex. This event begins a domino effect, with each of the remaining complement proteins performing its part in the attack sequence. The end result is a hole in the membrane of the offending cell and destruction of the cell. Activation of the complement cascade results in the formation of membrane attack complexes that insert in the cell membrane. These porelike structures allow sodium and water influx that causes the cell to swell and rupture.

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cytokines is large and growing; they can be grouped according to their source and function (Table 9.2).

These cytokines generally function as chemotactic factors (chemo- kines), antiviral factors, mediators of inflammation, hematopoietic factors, or activation signals for specific types of WBCs. Cytokines function to enhance and coordinate both innate and specific immune defenses. They are discussed in more detail in the sections that follow.

attack complex. The membrane attack complex has a direct cytotoxic effect by attacking cell membranes and disrupting the lipid bilayer. This action allows free movement of sodium and water into the target cell, which causes it to rupture (see Fig. 9.16). The complement system is a potent inflammatory and cytotoxic system that is carefully regulated by inhibitory factors. Normal host cells produce membrane and inhibitory plasma proteins that prevent complement binding to their surface (e.g., C1 inhibitor, protein S).

Kinins Bradykinin and kallidin are two of the many kinins present in the body. Kinins are small polypeptides that cause powerful vasodilation. They are especially active in the inflammatory process. The kinin system is linked to the clotting system via the Hageman factor (XII) and is activated with the activation of clotting. The first step in this process is the conver- sion of factor XII to factor XIIa (Fig. 9.17). Factor XIIa converts a substance known as prekallikrein to kallikrein. Kallikrein converts precur- sor substances known as kininogens to kinins. The most prevalent is kallidin, which is then converted to bradykinin. Activated kinins cause increased vascular permeability, vasodilation, and smooth muscle contraction. Kinins are also responsible for pain, which is one of the classic signs of inflammation.

Clotting Factors The blood coagulation cascade’s major purpose is to stop bleeding. It is also intimately involved in inflammation and triggering of the kinin system. The key linkage between the inflammatory response and clotting system is activated factor XII (Hageman factor) (see Fig. 9.17). (The blood coagulation cascade is discussed in detail in Chapter 14.) Activation of the coagulation cascade results in the formation of insoluble fibrin strands, which provide an effective barrier to the spread of infection. Clot formation also activates the fibrinolytic cascade, which splits fibrin proteins. Some of the fibrin degradation products are chemotactic signals for neutrophils.

Cytokines and Chemokines Cytokines are polypeptide signaling molecules that affect the function of other cells by stimulating surface receptors. Cytokines function in a complex intercellular communication network. WBC cytokines have previously had many names, including monokines, lymphokines, and interleukins, depending on their cell of origin. The number of known

FIG 9.17 Common linkage of the kinin and coagulation systems through the activation of factor XII (Hageman factor). XIIa, Activated factor XII.

KEY POINTS • The primary lymphoid organs are the thymus and bone marrow. T cells

develop in the thymus, whereas B cells develop in the bone marrow. Mature lymphocytes then migrate to secondary lymphoid structures, including the spleen and lymph nodes.

• Blood cells are produced in the bone marrow in response to specific hema- topoietic growth factors. Granulocytes (neutrophils, basophils, eosinophils) and monocytes (macrophages) are phagocytic cells that provide innate protec- tion. Lymphocytes (B cells, T cells) are specific cells that react only to particular antigens. Natural killer (NK) cells are lymphocytes that lack T-cell and B-cell markers and function in innate immune responses. Other blood components produced by bone marrow are erythrocytes and platelets.

• Neutrophils are the most numerous WBCs in blood. A large storage pool lies in the bone marrow and can be mobilized in response to antigen. Neutrophils are the predominant WBC type mobilized in early infection. They migrate to the area by following chemotactic factors and perform phagocytic functions. During acute bacterial infection, larger numbers of immature neutrophils (bands) are released into the blood, which is termed a “shift to the left.” Chronic infections may produce a shift to the right with more segmented neutrophils than normal.

• Monocytes located in tissue are called macrophages. Monocytes and macrophages are distributed in strategic locations throughout the body, including the skin, lungs, gastrointestinal tract, liver, spleen, and lymph. Macrophages are powerful phagocytes and are predominant in late inflammation.

• T lymphocytes, the major effectors of cell-mediated immunity, interact with specific antigens on cell surfaces. They are important in immunity against foreign, infected, or mutant cells. In addition, they secrete cytokines that boost the immune response of B cells and other cell types. T cells are composed of two main subtypes called CD4 (helper) and CD8 (cytotoxic). B lymphocytes are the major effectors of antibody-mediated immunity.

• The complement system consists of about 30 plasma proteins that interact in a cascade fashion to produce important mediators of inflammation and immunity. The cascade can be activated by microbial antigens (alternative pathway) or by antigen–antibody complexes (classical pathway).

• Cytokines are peptide factors released by immune cells. They have many functions, including as inflammatory mediators, chemotaxins, intercellular communication signals, growth factors, and growth inhibitors. Macrophages and lymphocytes are important sources of immune cytokines.

INNATE DEFENSES AND INFLAMMATION Inflammation occurs when cells are injured, regardless of the cause of the injury. It is a protective mechanism that also begins the healing process. The inflammatory response has three purposes: (1) to neutralize and destroy invading and harmful agents, (2) to limit the spread of harmful agents to other tissue, and (3) to prepare any damaged tissue for repair. Inflammatory reactions increase capillary permeability such that phagocytic cells, complement, and antibodies can leave the blood- stream and enter tissues where they are needed.

Five cardinal signs of inflammation have been described: (1) redness (rubor), (2) swelling (tumor), (3) heat (calor), (4) pain (dolor), and

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TABLE 9.2 Selected Immune Cytokines and Their Functions

Cytokine Origin Function

IFN-α Macrophages and induced by RNA or DNA viruses and by single- or double-stranded polyribonucleotides

Inhibits virus replication, toxic to cancer cells, stimulates leukocytes, facilitates NK cell activity, produces fever, increases B- and T-cell activity

IFN-β Fibroblasts and induced by RNA or DNA viruses and by single- or double-stranded polyribonucleotides

Inhibits virus replication, toxic to cancer cells, facilitates NK cell activity, produces fever

IFN-γ T cells (TH1 and CD8+) and NK cells Promotes antigen expression via MHC I and II, activates macrophages, inhibits cell growth, induces myeloid cell lines, promotes B cell switch to IgG

IL-1 Mononuclear phagocyte Stimulates TH17 cells and macrophages, induces acute phase reaction of inflammation, produces fever; similar to TNF and endogenous pyrogen

IL-2 T helper cells (TH1) Promotes growth of T cells, enhances function of NK cells, assists T-cell maturation in thymus and B-cell proliferation

IL-3 T cells, endothelial cells, fibroblasts, other cells Induces proliferation and differentiation of other lymphocytes, pluripotent stem cells, mast cells, and granulocytes

IL-4 T helper cells (TH2) Promotes T-cell/B-cell interactions, promotes synthesis of IgE by B-cell and TH2 cell growth, promotes mast cell and hematopoietic cell growth

IL-5 T helper cells (TH2) Promotes growth and differentiation of B cells to secrete IgA, induces differentiation of eosinophils

IL-6 Mononuclear phagocytes, T cells and nonlymphoid cells (e.g., endothelium)

Promotes immunoglobulin secretion by B cells, induces fever, promotes release of inflammation factors from liver cells, promotes differentiation of hematopoietic stem cells and nerve cells

IL-7 Stromal cells in bone marrow Stimulates immature lymphocytes to divide to produce B and T cells IL-8 Macrophages Enhances inflammation and chemotaxis (CXCL chemokine) IL-9 TH2 cells Enhances growth of T helper cells, B cells, and mast cells IL-10 TREG cells and macrophages Inhibits activation of macrophages and dendritic cells, inhibits IL-12

production IL-11 Stromal cells in bone marrow Stimulates platelet production IL-12 Macrophages, dendritic cells Enhances TH1 cell activities and release of IFN-γ by T cells and NK cells IL-13 TH2 cells Stimulates B-cell growth and IgE production, suppresses macrophages IL-14 T cells Induces B-cell proliferation IL-15 Macrophages and various other cell types Similar actions to IL-2, enhances proliferation of T cells (CD8) and NK cells IL-16 CD8+ T cells CD4+ cell chemotaxis, suppresses viral replication of HIV IL-17 CD4+ T cells Stimulates production of colony-stimulating factors and chemokines IL-18 Macrophages in response to microbes Increases NK-cell proliferation and secretion of IFN-γ by TH1 IL-19 Macrophages Stimulates macrophage IL-1 secretion IL-20 Monocytes Stimulates hematopoietic stem cells IL-21 TH2 and TH17 and TFH cells Activates B cells, stimulates production of NK cells IL-22 TH17 cells Epithelial cells, increased barrier function, defensin production IL-23 Macrophages and dendritic cells Differentiation of TH17 cells IL-24 Monocytes, T cells Monocyte inflammatory cytokine production IL-25 T cells, mast cells and macrophages Stimulates production of cytokines by TH2 cells (IL-4, IL-5, IL-13) IL-26 T cells, monocytes Uncertain IL-27 Macrophages and dendritic cells Inhibits TH1 cells IL-31 TH2 cells Uncertain IL-33 Endothelial cells, fibroblasts TH2 cell development TNF-α Macrophages Induces leukocytosis, fever, weight loss, inflammation, necrosis of some

tumors; stimulates lymphokine synthesis; activates macrophages; toxic to viruses and tumor cells

TNF-β TREG cells Inhibits B-cell and T-cell proliferation G-CSF, M-CSF, GM-CSF Macrophages, T cells, fibroblasts Stimulates granulocyte and monocyte production in bone marrow TGF-β T cells, macrophages Inhibits T cells, B cells, and macrophages

Chemokines CXCL 1–16 Macrophages and various cells in tissues Recruitment of neutrophils, macrophages, lymphocytes CCL 1–28 Macrophages and various cells in tissues Recruitment of neutrophils, macrophages, lymphocytes

GM-CSF, Granulocyte-macrophage colony-stimulating factor; HIV, human immunodeficiency virus; IFN, interferon; IL, interleukin; NK, natural killer; TNF, tumor necrosis factor; TGF, transforming growth factor.

CHAPTER 9 Inflammation and Immunity 171

known to be present on the cell membrane for some time, but now their presence inside of cells has been described. When these internal receptors detect foreign matter, such as viral RNA or DNA, an internal cascade of events can assemble a group of proteins into a functional unit called an inflammasome. Caspase-1 is an important component of the inflammasome that increases the production and release of interleukin-1, an important proinflammatory cytokine that causes fever and contributes to recruitment and activation of immune cells.

Increased Vascular Permeability Prostaglandins and leukotrienes are important mediators of inflammation (Table 9.3). Mast cells are an important source of these inflammatory chemicals. Mast cells in the area of injury degranulate and release packets of histamine and other inflammatory chemicals. One of the early actions of these mediators is to vasodilate and cause endothelial cells to begin retraction and rounding up, thus increasing capillary permeability. The greater volume of blood increases the amount of pressure within the blood vessels (hydrostatic pressure). The increased pressure along with increased permeability pushes fluid out of the blood vessels and into the surrounding tissue, contributing to local swelling. Because of the dilated blood vessels and open capillaries, more blood is carried to the injured area and contributes to the redness, pain, heat, and swelling of inflammation (Fig. 9.19).

Histamine is an early mediator of this inflammatory response. It is such a potent vasodilator that it can cause significant reductions in blood pressure when released in excessive amounts. Histamine also causes bronchial constriction and mucus production. Histamine receptor–blocking agents are widely used in allergic reactions, such as skin reactions and hay fever, to suppress these inflammatory actions of histamine.

Prostaglandins and leukotrienes are phospholipid compounds formed from arachidonic acid. The prostaglandins involved in inflammation contribute to vasodilation and increased permeability (Fig. 9.20). Pros- taglandin D2 also acts as a chemotactic factor and stimulates neutrophil emigration. Prostaglandins cause pain by enhancing the sensitivity of pain receptors. They arise from the cyclooxygenase pathway and can be inhibited by drugs that block enzymes in this pathway, such as aspirin.

Five types of leukotrienes are generated from the lipoxygenase pathway: A4, B4, C4, D4, and E4. Leukotriene B4 is a potent chemotactic agent that causes aggregation of leukocytes; leukotrienes C4, D4, and E4 are inflammatory and cause smooth muscle contraction, bronchospasm, and increased vascular permeability. Leukotriene receptor–blocking agents can be used to inhibit the inflammatory actions of these chemicals.

During the early phase of tissue inflammation, platelets move into the site and adhere to exposed vascular collagen. The platelets release fibronectin to form a meshwork trap and stimulate the intrinsic clotting cascade to help reduce bleeding. Platelets release a number of peptide growth factors, including platelet-derived growth factor and insulin-like growth factor. Platelet-derived growth factor stimulates fibroblast cell proliferation, and insulin-like growth factor type 1 is a potent vascular endothelial cell chemotactic factor. Triggering of the blood coagulation cascade also occurs and leads to the formation of a fibrin clot. Usually, early clot formation occurs within several minutes. Fibrin is also deposited in the lymph system, where it causes lymphatic blockage. Lymphatic blockage “walls off” the area of inflammation from the surrounding tissue and delays the spread of toxins.

The vascular changes that occur soon after injury are beneficial to the injured tissue because irritating or toxic agents are diluted by the fluid that leaks out of the blood vessels into surrounding tissue. In addition, when the fluid leaves the blood vessels, the remaining blood becomes viscous (thick) and circulation is slowed, facilitating neutrophil emigration.

(5) loss of function (functio laesa). The suffix -itis is commonly used to describe conditions associated with inflammation. For example, appendicitis, tendonitis, and nephritis refer to inflammation of the appendix, tendon, and kidney, respectively.

Inflammation can be caused by many conditions. Any injury to tissue will evoke an inflammatory response. Injury can arise from sources outside the body (exogenous) or from sources inside the body (endogenous). Surgery, trauma, burns, and skin injury from chemicals are all examples of exogenous injuries. Endogenous injuries may result from tissue ischemia such as myocardial infarction or pulmonary embolism.

Inflammation and infection are commonly confused because they often coexist. Under normal conditions, infection is always accompanied by inflammation; however, not all inflammation involves an infectious agent. For example, inflammation can occur with sprain injuries to joints, myocardial infarction, sterile surgical incisions, thrombophlebitis, and blister formation as a result of either temperature extremes or mechanical trauma.

Inflammation may be categorized as either acute or chronic. Acute inflammation is short in duration, lasting less than 2 weeks, and involves a discrete set of events. Chronic inflammation tends to be more diffuse, extends over a longer period, and may result in the formation of scar tissue and deformity.

INFLAMMATION Events in the inflammatory response to bacterial antigens and tissue injury include (1) vasodilation and increased vascular permeability, (2) recruitment and emigration of leukocytes, and (3) phagocytosis of antigens and debris. The general inflammatory response is outlined in Fig. 9.18.

Innate immune cells, including neutrophils, macrophages, and some tissue cells, are equipped with pattern recognition receptors that allow them to bind to foreign particles and produce inflammatory cytokines that are released to initiate inflammatory cascades. Pattern recognition receptors, such as mannose receptors and Toll-like receptors, have been

Injury

Vasoactive chemicals

Vasodilation

Phagocytosis

Endothelial binding of

neutrophils and macrophages

Chemokines

Emigration of neutrophils and macrophages

into tissue

FIG 9.18 Tissue injury stimulates the release of a number of chemical mediators that promote vasodilation, chemotaxis, and binding of neu- trophils and macrophages to area capillaries. These events facilitate the emigration of neutrophils and macrophages into the tissue, where they begin phagocytosis.

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neutrophils are highly mobile, they are first on the scene to begin phagocytosis and production of collagenase to degrade dead tissue. Monocytes are slightly slower to arrive at an area of inflammation but use a similar process of emigration to gain entry to the area of tissue injury.

Eosinophils and NK cells may also respond to the site of inflammation. Eosinophils are rich in chemical mediators such as hydrolases and peroxidases, which may contribute to the inflammatory process. NK cells are most effective in recognizing virally infected cells and opsonized microbes.

Phagocytosis Once neutrophils and monocytes (macrophages) enter the tissue, they begin the process of phagocytosis (Fig. 9.22). These cells produce a wide variety of enzymes that digest protein structures. Some of these enzymes include lysozyme, neutral proteases, collagenase, elastase, and acid hydrolases. Neutrophils and macrophages specialize in collagen and extracellular matrix degradation. Peptide bonds are cleaved in the extracellular matrix by collagenase, elastase, proteinase, and gelatinase. If the microbe is small enough to be internalized, it will be captured by the phagocyte and endocytosed into a phagosome. The phagosome then merges with a lysosome containing degradative enzymes. Large antigens may trigger the neutrophil to release its degradative enzymes extracellularly, causing damage to local tissues.

Oxidizing agents, the most destructive of the inflammatory cell products, are formed as a result of the phagocyte oxidase enzyme system on the membrane of the lysosome. Neutrophils are capable of synthesizing and assailing microorganisms with these oxidizing agents, which include the following oxygen radicals: superoxide (O2

−), hydrogen peroxide (H2O2), and hydroxyl ions (OH

−). Oxidizing agents directly attack cell membranes and thereby increase permeability. Nitric oxide products may also be produced by inducible nitric oxide synthase (iNOS) and function in concert with oxygen radicals to attack microbial molecules (see Fig. 9.22).

Because acute inflammation can cause severe tissue damage, it is not surprising that a system of inactivators is present. An important inhibitor of inflammatory damage is α1-antiprotease. Antiproteases are made in the liver and circulate continuously in the bloodstream. α1- Antiprotease inhibits the destructive proteases released from activated neutrophils. A deficiency of antiproteases can predispose an individual to inflammatory tissue destruction.

Neutrophils have a limited capacity to phagocytose foreign and inflammatory debris. Once the neutrophil leaves the circulation to fight

Emigration of Leukocytes As blood flows through areas of inflammation, neutrophils move to the sides of the blood vessels and roll along the endothelium of the vessel wall. This process is referred to as margination or pavementing. Normally, neutrophils slide past the capillary endothelial cells and do not stick. Injured tissue triggers the expression of adhesion molecules on the surface of endothelial cells, and the adhesion molecules bind to receptors on neutrophils (Fig. 9.21). These receptors, called selectin and chemokine receptors, help neutrophils stick and roll along the capillary endothelial surface. Binding to and subsequent movement through the capillary wall are accomplished by another group of receptors called integrins. Chemokines present on the endothelium enhance the binding affinity of integrins so the neutrophil can attach firmly to the vessel wall. The process of passing through the blood vessel walls and migrating to the inflamed tissue is referred to as emigration or diapedesis. Diapedesis begins within a few minutes to hours of injury. Even though the spaces between endothelial cells lining the vessels are much smaller than the neutrophils, neutrophils are able to slide through a small portion at a time.

Neutrophils are attracted to the inflamed tissue by a process called chemotaxis. Biochemical mediators that attract neutrophils include bacterial toxins, degenerative products of the inflamed tissue, the C5a complement fragment, and other substances. Neutrophils are thus guided through the tissue to an area of injury by these chemicals. Because

TABLE 9.3 Mediators of Acute Inflammation

Mediator Vasodilation

INCREASED PERMEABILITY

Chemotaxis Opsonin PainImmediate Sustained

Histamine + +++ − − − − Serotonin (5-HT) + + − − − − Bradykinin + + − − − ++ Complement 3a − + − − − − Complement 3b − − − − +++ − Complement 5a − + − +++ − − Prostaglandin (E2) +++ + +? − − − Leukotrienes (B4, D4) − +++ +? +++ − − Lysosomal proteases − − ++* − − − Oxygen free radicals − − ++* − − −

Data from Roitt I et al: Immunology, ed 6, St Louis, 2001, Mosby. *Proteases and oxygen-based free radicals derived from neutrophils are believed to mediate a sustained increase in permeability by means of their damage to endothelial cells.

Tissue damage

Vasodilation

PAIN HEAT SWELLING REDNESS

Increased permeability

Neutrophil emigration

Release of vasoactive and chemotactic

factors

FIG 9.19 Cardinal signs of acute inflammation result mainly from vasodilation and increased vascular permeability.

CHAPTER 9 Inflammation and Immunity 173

Cell membrane phospholipids

Arachidonic acid HPETEs HETEs

5-HETE

Leukotriene B4

Phospholipases

Cyclooxygenase 5-Lipoxygenase

12-Lipoxygenase

Steroids inhibit

COX-1 and COX-2 inhibitors, aspirin,

indomethacin inhibit

Other lipoxygenases

Prostaglandin G2 (PGG2)

Leukotriene A4 (LTA4)

Leukotriene C4 (LTC4)

Leukotriene D4 (LTD4)

Leukotriene E4 (LTE4)

Prostaglandin H2 (PGH2)

5-HPETE

Thromboxane A2 TXA2

Prostacyclin PGI2

Causes vasodilation, inhibits platelet aggregation

Causes vasoconstriction, promotes platelet aggregation

PGE2PGD2

Vasodilation Increased vascular permeability

LipoxinB4LipoxinA4

Inihibition of inflammation

Chemotaxis

Vasoconstriction Bronchospasm Increased vascular permeability

FIG 9.20 Generation of prostaglandins, thromboxane, and leukotrienes from arachidonic acid and roles in inflammation. HETEs, Hydroeicosatetraenoic acids; HPETEs, hydroperoxyeicosatetraenoic acids.

Leukocyte Rolling

Integrin (low affinity state)

Integrin (high affinity state)

Integrin ligand

Macrophage with microbes

Fibrin and fibronectin (extracellular matrix)

Selectin ligand

Selectin

Chemokines

Chemokine

Proteoglycan

Cytokines (TNF, IL-1)

Integrin activation by chemokines

Stable adhesion

Migration through

endothelium

FIG 9.21 Emigration of neutrophils from the bloodstream into tissue is mediated by receptor interactions with the capillary endothelium. With inflammation and injury, endothelial cells begin to express binding molecules on their cell surfaces (selectins). Leukocytes also have selectins, which can bind to endothelial adhesion proteins. The selectin interactions cause the leukocytes to stick and roll. Chemokines on the surface of endothelial cells interact with neutrophils (and macrophages) to increase the binding affinity of integrin receptors on leukocytes. Firm attachment and diapedesis through the capillary wall is facilitated by integrins that allow the neutrophils to bind to endothelial cells and extracellular matrix and then pull themselves into the tissue. IL, Interleukin; TNF, tumor necrosis factor.

174 UNIT III Defense

and persists for 2 weeks. The major cells involved in this phase include fibroblasts, endothelial cells, and myofibroblasts.

Fibroblasts are found all over the body and are thought to originate in mesenchymal primitive tissue. They synthesize connective tissue and are able to migrate. Fibroblasts are stimulated to make collagen, pro- teoglycans, and fibronectin by a variety of growth factors. Macrophages secrete lactate and release growth factors that stimulate fibroblasts. Fibroblasts respond to contact and density inhibition and thereby facilitate orderly cellular growth. Myofibroblasts develop at the wound edge and induce wound contraction.

Endothelial cells grow into the connective tissue gel stimulated by angiogenic substances. They usually develop capillary beds from existing vessels. The new capillaries can transport nutrients for tissue repair and wound healing. However, because the new capillaries are leaky, they contribute to continuing edema.

Regeneration of damaged tissue into the preexisting tissue type requires survival of the basement membrane and tissue stem cells. Some cell types regenerate constantly; among these types are the epithelial cells of the skin and mucous membranes, bone marrow cells, and lymphoid cells. Cells of the liver, pancreas, endocrine glands, and renal tubules are also able to regenerate when necessary. However, some cell types, such as neurons and muscle cells, regenerate poorly. The maturation phase of wound healing occurs several weeks after the injury and may last for 2 years or more. It is characterized by wound remodeling by fibroblasts, macrophages, neutrophils, and eosinophils. Wound remodel- ing is the process of collagen deposition and lysis with debridement of the wound edges. During this phase the wound changes color from

an infection, it is unable to return and will die at the site. When phagocytosis is incomplete, a collection of dead neutrophils, bacteria, and cellular debris, called pus, may form at the site. Macrophages are left with the job of removing spent neutrophils and preparing the site for healing. A predominance of monocytes and macrophages in an inflamed area signals the beginning of chronic inflammation.

Chronic Inflammation Macrophages are essential for wound healing because of their phagocytic and debridement functions. Macrophages produce proteases that help in removing foreign protein from the wound. Macrophages also release tissue thromboplastin to facilitate hemostasis and stimulate fibroblast activity. Macrophages secrete other peptide growth factors such as angiogenic factor, which encourages the growth of new blood vessels. Macrophages also phagocytose spent neutrophils and their degradation products so they do not interfere with healing. Prolonged inflammation may impair healing and result in an accumulation of macrophages, fibroblasts, and collagen, called a granuloma. Granulomas are usually evident on examination of tissue biopsy as clusters of macrophages surrounding particulate matter or resistant microbes such as Mycobac- terium tuberculosis. Fibrosis and scarring are evident because normal parenchyma is replaced with fibrous tissue.

HEALING Healing of tissues after inflammation can occur in different ways over time. Usually the reconstructive phase begins 3 to 4 days after injury

Microbe

ROS

Microbe

Phagocyte oxidase

Phagosome

C3b receptor

Fcγ receptor

Mannose receptor

Scavenger receptor

Other microbe recognition receptor

CD14/ TLR

Lysosome

iNOS

Phagolysosome

LysozymesNeutrophil or macrophage

ROS O2

O2 NO

FIG 9.22 Neutrophils and macrophages have a number of different receptors on their surface that enable them to bind to components of microbes or to opsonins like IgG and complement. Bound microbes are internalized into phagosomes that fuse with lysosomes containing numerous enzymes. Some of these enzymes degrade proteins (proteolytic), and others such as oxidase and inducible nitric oxide synthase (iNOS) produce free radicals that attack molecular bonds. When phagocytes are strongly stimulated or microbes are too large to internalize, the lysosomal enzymes may be activated or released at the cell surface, causing tissue damage and inflammation. ROS, Reactive oxygen species.

CHAPTER 9 Inflammation and Immunity 175

amyloid A. CRP binds to phospholipids on bacterial cell membranes and acts as an opsonin to facilitate phagocytosis.

When the liver releases acute phase proteins, the level of fibrinogen in the serum is increased. Fibrinogen coats the surface of red blood cells and reduces their charge so that they aggregate more readily. A blood test called the erythrocyte sedimentation rate (ESR, “sed rate”) provides a simple measure of the level of inflammation in an individual. Thus an elevated ESR indicates the presence of inflammation in the body. The greater the inflammation, the faster the red blood cells precipitate to the bottom of a test tube and the higher the ESR. The ESR is a nonspecific but clinically useful indicator of inflammation. Serum CRP activity is also used as a nonspecific indicator of inflammation in a manner similar to the ESR.

bright red to pink to whitish. As long as a wound is pink, the maturation phase is not completed.

INFLAMMATORY EXUDATES Exudate is fluid that leaks out of blood vessels, combined with neutrophils and the debris from phagocytosis. Exudates may vary in composition, but all types have similar functions, including (1) transport of leukocytes and antibodies, (2) dilution of toxins and irritating substances, and (3) transport of the nutrients necessary for tissue repair.

Serous exudate is watery, has a low protein content, and is similar to the fluid that collects under a blister. This type of exudate generally accompanies mild inflammation. With mild inflammation, the perme- ability of the blood vessels is not greatly changed. As a result, only some protein molecules escape from vessels, and serous exudate, with a low protein content, develops. Small amounts of red blood cells may leak into the serous fluid with capillary injury, resulting in a pink-tinged drainage called serosanguineous drainage.

With greater injury, more inflammation occurs and the blood vessels become more permeable. Because of this increased permeability, more protein can pass through the vessel walls. Fibrinogen, a large protein molecule, can pass through a highly permeable blood vessel wall. Fibrinous exudate is sticky and thick and may have to be removed to allow healing; otherwise, scar tissue and adhesions may develop. However, in some instances fibrinous exudate may be beneficial. In the case of acute appendicitis, fibrinous exudate may actually wall off and localize the infection and prevent its spread.

Purulent exudate is called pus. Purulent exudate generally occurs in severe inflammation accompanied by bacterial infection and is primarily composed of neutrophils, protein, and tissue debris. Large pockets of purulent exudate, called abscesses, must generally be removed or drained for healing to take place.

Hemorrhagic exudate has a large component of red blood cells. This type of exudate is usually present with the most severe inflammation. Hemorrhagic exudate occurs with severe leakage from blood vessels or after necrosis or breakdown of blood vessels.

SYSTEMIC MANIFESTATIONS OF INFLAMMATION Inflammation is associated with both localized and systemic signs and symptoms. The localized symptoms, described previously, occur with both acute and chronic inflammation. Depending on the magnitude of injury and the resistance of the individual, localized inflammation can lead to systemic involvement. Systemic responses include fever, neutrophilia (increased blood neutrophil count), lethargy, and muscle catabolism. Three macrophage-derived cytokines—IL-1, IL-6, and TNF-α—are responsible for most of the systemic effects of inflammation.

TNF-α and IL-1 act on the brain to raise body temperature, induce sleep, and suppress appetite. By raising the set point for body temperature, these cytokines induce conservation of heat through vasoconstriction, as well as increased heat production through shivering. An increase in body temperature is assumed to improve the immune response; however, the mechanism is unclear. IL-1 is responsible for stimulating the release of neutrophils from bone marrow storage sites, thus producing neu- trophilia. All three cytokines act on skeletal muscle to enhance protein catabolism, which provides an available pool of amino acids for efficient antibody production by plasma cells.

The liver is another important target for IL-1 and TNF-α. These cytokines induce the liver to release a number of proteins collectively called acute phase proteins, which include complement components, clotting factors, and protease inhibitors (Fig. 9.23). Two of the most important acute phase proteins are C-reactive protein (CRP) and serum

C-reactive protein

Serum amyloid A

Protease inhibitors (α1-antitrypsin)

IL-1, TNF-α

Clotting factors (fibrinogen, vWB factor)

Complement (C2, C3, C4, C5)

Liver

FIG 9.23 The liver is a target for three important cytokines: interleukin-1 (IL-1) and tumor necrosis factor-α (TNF-α). In response to these cytokines, the liver releases a number of proteins, collectively called acute phase proteins. vWB, von Willebrand factor.

KEY POINTS • Previous exposure to foreign antigens is not required for the activation of

innate immune defenses. Inflammation is an important aspect of innate immunity that involves localization of harmful agents and the movement of phagocytic cells to the area. Classic manifestations of inflammation are redness, swelling, heat, pain, and loss of function.

• Inflammatory chemicals such as histamine, prostaglandins, and leukotrienes are released from injured tissues, mast cells, macrophages, and neutrophils. These chemicals increase vascular permeability, vasodilate, and attract immune cells to the area (chemotaxis).

• Phagocytes migrate to the inflamed area, collect at the side of the vessel, and squeeze through into the tissue. Emigration of neutrophils and macro- phages is facilitated by chemokines, selectins, and integrins present on the surface of endothelial cells and leukocytes. Neutrophils arrive in large numbers in acute bacterial infection and begin active phagocytosis. Neu- trophils and macrophages produce proteolytic enzymes and oxidizing agents to destroy and digest antigens. With chronic inflammation, macrophages and lymphocytes predominate.

• Healing is mediated by growth factors released from platelets and immune cells that stimulate fibroblasts to divide and manufacture extracellular matrix proteins. Endothelial cells respond to angiogenic growth factors by forming capillary networks.

• Inflammatory exudate functions to transport immune cells, antibodies, and nutrients to the tissue and dilute the offending substances. Serous exudate

176 UNIT III Defense

for inspection by T cells. Cells displaying foreign antigens stimulate an immune response, whereas those displaying self antigens do not because self-reacting T cells are not allowed to survive in the thymus. Genetic diversity in MHC gene expression is believed to be important to the preservation of a species because new pathogens are likely to encounter at least some individuals with MHC genotypes that can recognize and eliminate these pathogens.

ANTIGEN PRESENTATION BY MHC Nucleated cells in the body are capable of expressing MHC class I proteins on their cell surfaces, whereas only certain specialized cells, primarily dendritic cells, macrophages, and B cells, are able to express MHC class II proteins. Cytotoxic T cells are able to recognize foreign antigen bound to MHC class I proteins, whereas T helper cells recognize foreign antigen bound to MHC class II proteins. T cells are screened during development in the thymus so that they recognize self MHC

SPECIFIC ADAPTIVE IMMUNITY The specific immune system uses remarkably effective and adaptive defense mechanisms capable of recognizing foreign invaders, destroying them, and retaining a memory of the encounter such that an even more effective defense (adaptive) will be achieved after subsequent exposure. As previously described, B and T lymphocytes are the cellular mediators of specific adaptive immunity. B cells are said to provide “humoral” immunity because the antibodies they produce are found in body fluids, or “humors.” T cells provide “cell-mediated” immunity because they recognize antigen presented on the surface of cells. To achieve immunity against specific antigens, B and T lymphocytes must be capable of recognizing an enormous range of foreign antigen yet not be reactive to self tissues.

Differentiation between self and nonself requires a complex lym- phocyte development process in which self-reactive lymphocytes are destroyed and potentially useful lymphocytes are preserved. The MHC proteins have a primary role in enabling lymphocytes to react to foreign antigen while remaining tolerant to self antigen. Self-tolerance is not always effectively maintained, and impairment in self-tolerance can result in the development of autoimmune disorders (see Chapter 10).

MAJOR HISTOCOMPATIBILITY COMPLEX A cluster of genes on chromosome 6 is known as the major histocompat- ibility complex (MHC). In humans, the MHC is also known as the human leukocyte antigen (HLA) complex. The proteins made by these genes are displayed on the surface of body cells and mark them as “self.” The MHC contains three classes of genes: I, II, and III (Fig. 9.24). Class I and II genes code for proteins that display, or “present,” antigens on the surface of cells. Antigen presentation is a vital first step in the initiation of an immune response. T lymphocytes cannot recognize foreign antigens unless they are displayed on MHC proteins on the surface of a cell. Class III genes code for a variety of proteins, many of which are important to inflammatory reactions, including several complement proteins.

A great deal of polymorphism is found in the MHC class I and II genes, which means that it is highly unlikely that one individual will have exactly the same MHC genotype as another individual. For example, three gene loci for MHC class I proteins (A, B, C) are located on each chromosome 6, and an individual inherits one chromosome from each parent for a total of six MHC class I genes. Each of these genes has many different forms (alleles) such that each of the six is likely to be different (Fig. 9.25). Related individuals will generally be more similar but not identical (unless identical twins). The “matching” of MHC gene expression is an important consideration for tissue and organ transplanta- tion. The closer the match is, the less likely that the host will reject the transplant. An individual also receives six MHC class II genes that are expressed on specialized antigen-presenting cells, such as dendritic cells, macrophages, and B cells. Because of the potential for mixing and matching of class II MHC gene products, an individual may express 10 to 20 different MHC class II proteins. The MHC class I and II proteins on the surface of cells display both self and foreign antigens

Receptors for antigen presentation

found on macrophages and B cells

Class I Class II Class III

Receptors for antigen presentation

found on nucleated cells

Complement components and others

FIG 9.24 Major histocompatibility complex genes are categorized into three main groups known as class I, II, and III. Class I and II genes code for antigen-presenting proteins, whereas class III genes code for a heterogeneous group of proteins, many of which serve immune functions.

Class II MHC

DP DQ DR

Class I MHC Class III

B C A

e.g.: DPw1 DPw2 DPw3 DPw6

e.g.: DQ1 DQ2 DQ3 DQ9

e.g.: DR2 DR3 DR4 DR53

e.g.: B5 B7 B27 B81

e.g.: Cw1 Cw2 Cw3 Cw10

e.g.: A1 A2 A3 A80

FIG 9.25 Each individual receives six class I major histocompatibility complex (MHC) genes, including pairs of A, B, and C genes. One member of the pair is inherited from each parent. MHC class I genes are expressed in all nucleated cells of the body. Each individual also receives six class II MHC genes, three from each parent. However, class II proteins are composed of two polypeptide chains such that an individual may have 10 to 20 different MHC class II protein molecules. Class II MHC proteins are expressed on the surface of specialized antigen-presenting cells like macrophages, dendritic cells, and B cells. The structure of an individual’s MHC proteins is assessed to determine the “tissue type” when matching for tissue transplantation procedures.

is watery and low in protein; fibrinous exudate is thick, sticky, and high in protein; purulent exudate contains infective organisms, leukocytes, and cellular debris; and hemorrhagic exudate contains red blood cells.

• Systemic manifestations of inflammation include fever, neutrophilia, lethargy, muscle catabolism, increased acute phase proteins (CRP), and increased ESR. These responses are attributable to the IL-1, IL-6, and TNF-α released from macrophages and inflamed tissues.

CHAPTER 9 Inflammation and Immunity 177

9.27). The MHC I–antigen complexes then travel to the cell membrane, where they are displayed. Recognition of foreign antigen in association with the MHC I protein on the cell surface targets the presenting cell for destruction by cytotoxic T cells. When the cytotoxic T cell binds to the MHC I–antigen complex (and coreceptors), it is stimulated to release enzymes and pore-forming proteins (perforins) that lyse the target cell. Cytotoxic T cells can only recognize an antigen if it is physically bound to an MHC class I molecule. Cytotoxic T cells are thus said to be MHC class I restricted.

MHC Class II Presentation MHC class II proteins are used to present antigens obtained from extracellular sources. Extracellular antigens must first be engulfed by the antigen-presenting cell. Cells of the monocyte–macrophage lineage, dendritic cells, and B cells are responsible for presenting antigen by MHC II. Macrophages and dendritic cells obtain foreign antigens by phagocytosis and are thus able to process and present a large number of different antigens. They are said to be “nonspecific” for this reason. B cells, on the other hand, are particular about the antigens that they engulf. The antigen must specifically bind to the BCR to be ingested by a B cell. Each B cell has only one type of BCR and therefore processes and presents only one specific antigen. The specificity of the BCR corresponds to the antibody that the activated B cell will produce. The process of B-cell activation is explored in the section titled “Mechanisms of Humoral Immunity.”

After the antigen-presenting cell has ingested an antigen, it is degraded into fragments within the cellular phagosomes (endocytic vesicle). MHC II proteins are synthesized on the rough ER and pick up an antigen

proteins and do not react to self peptides displayed by self MHC proteins. This concept is explored further in the section “Mechanisms of Cell- Mediated Immunity.” The sources of antigen, mechanism of antigen processing, and T-cell response to antigen are quite different for MHC I and MHC II reactions.

MHC Class I Presentation Nucleated cells continuously produce MHC class I proteins on the rough endoplasmic reticulum (ER), where they are combined with various peptide fragments that are present in the cytoplasm. These peptides result from degradation of normal intracellular proteins. The MHC I–peptide complexes are cycled to the cell surface for inspection by T cells. Normal MHCs displaying normal cellular proteins are ignored by T cells. If abnormal proteins are produced in the cell, then the MHC I–peptide complex will be recognized as foreign and an immune response will occur. The peptide antigens presented on MHC I are of intracellular origin. Because viruses are able to gain access to cells directly, viral protein is a common source of foreign MHC class I antigens. Abnormal intracellular proteins produced by mutant cells may also be presented on MHC I, thus targeting them for immune destruction. Before intracel- lular proteins can be presented at the cell surface, they must be processed and transported to the ER, where they are combined with newly syn- thesized MHC class I protein (Fig. 9.26). Peptide fragments are generated in the cytoplasmic proteasomes and escorted through the ER by special transporters called transporters associated with antigen processing (TAPs). The TAPs are located near the MHC I complexes on the ER membrane and target the peptides to the MHC I–binding cleft. The MHC I–binding cleft can accommodate peptide fragments of 8 to 11 amino acids (Fig.

Class I MHC pathway ER

Cytosolic protein

Proteasome

Normal mRNA

TAP

CD8+ CTL

Peptides in cytosol

Viral RNARibosome

Virus

Class I MHC

FIG 9.26 Nearly all nucleated cells of the body are able to process and display antigen in association with major histocompatibility complex (MHC) class I protein. The antigens come from the intracellular compartment, and a common source of foreign antigen is viral infection. The viral proteins made within the cell’s cytoplasm are processed into peptide fragments in the proteasome and then enter the endoplasmic reticulum (ER) through TAP transporters. There they combine with MHC class I proteins. The MHC class I–antigen complex then shuttles to the cell surface within a vesicle. When the vesicle combines with the plasma membrane, the MHC class I–antigen complex is displayed on the cell surface. CTL, Cytotoxic T lymphocyte; TAP, transporter associated with antigen processing. (Redrawn from Abbas AK et al: Cellular and molecular immunology, ed 8, Philadelphia, 2015, Saunders, p 124.)

178 UNIT III Defense

C

C

α1 α2

α3

β2- microglobulin

Peptide-binding cleft Peptide

N N

Disulfide bond

Ig domain

Class I MHC

Transmembrane region

A B

FIG 9.27 Schematic (A) and ribbon (B) diagrams of the class I major histocompatibility complex molecule. Note that the peptide-binding cleft is formed from one polypeptide chain that restricts the size of peptide in the pocket to 8 to 11 amino acids. (From Abbas AK et al: Cellular and molecular immunology, ed 8, Philadelphia, 2015, Saunders, p 120.)

from the phagosome on their way to the plasma membrane (Fig. 9.28). The class II MHC molecule is formed by two protein chains, and the binding cleft is more flexible than that of MHC I proteins (Fig. 9.29). Peptides displayed by MHC class II proteins range in size from 10 to 30 amino acids. The MHC II–antigen complexes are then displayed at the cell surface where T helper cells can detect them. T helper cells can only recognize a foreign antigen if it is physically bound to an MHC II protein. T helper cells are thus said to be MHC II restricted. Naive T cells located in lymph nodes are usually presented with antigen by dendritic cells displaying foreign antigens on their MHC II proteins. Dendritic cells populate the body surfaces and mucous membranes. When they engulf antigen, they break their tissue attachments and migrate to lymph nodes where they interact with T helper cells.

MECHANISMS OF CELL-MEDIATED IMMUNITY T cells are able to recognize foreign antigen displayed on the surface of antigen-presenting cells through specialized receptors called T cell receptors (TCRs). Each T cell has tens of thousands of identical TCRs on its cell surface. Each T cell is thus able to recognize and respond to only a single antigenic epitope. This property is what makes T cells specific. The binding specificity of the TCR is determined by recombina- tion, rearrangement, and random mutations within the genes that code for the TCR-binding domain. Billions of different TCR amino acid sequences are possible, thus providing a tremendous diversity of potential antigen-binding specificities. This diversity increases the likelihood that one or more T cells will have the right TCRs to allow recognition of any of the various pathogens that may gain access to the body. The drawback to this random approach is that many TCRs will be useless or may bind self antigens. A rigorous selection process occurs in the

thymus such that self-reactive T cells are eliminated. This selection process requires at least two steps. In the first, T cells must demonstrate an ability to recognize self MHC proteins displayed on the surface of specialized thymic cells. Portions of the TCR must make appropriate contact with the MHC protein, or the T cell will not be able to respond to antigens presented on the cell surface. Expression of either CD4 or CD8 on the T cell helps determine which class of MHC the T cell must fit. T cells that do not have functional TCRs undergo apoptosis in the thymus. The second requirement is that the TCR does not bind tightly to MHC proteins that are displaying normal self-derived peptides. Tight binding to self peptides also triggers the cell to initiate apoptosis. T cells that pass these tests migrate to secondary lymphoid tissues to await foreign antigens. Exposure of a T cell to its corresponding antigen results in expansion of the T cell into a clone of cells that all recognize the same antigen. This process ensures that useful T cells are maintained in the body as memory cells, whereas T cells that do not encounter antigen will not proliferate. Members of the T-cell clone migrate to lymphoid organs throughout the body, where they can respond rapidly should the same antigen reenter the system. The life span of mature T cells is long, but the numbers of memory cells in a clone will decline over time. However, intermittent exposure to the antigen is likely to occur and will stimulate proliferation and maintain immunity.

The two major types of T cells, T helper cells and cytotoxic T cells, react quite differently to activation of their TCRs by antigen and are therefore described separately in the following sections.

T Helper Cells (CD4+) T helper cells recognize antigen in association with MHC class II molecules. The CD4 protein is needed to enable T helper cells to bind the MHC II protein, whereas the TCR recognizes the specific antigen

CHAPTER 9 Inflammation and Immunity 179

Class II MHC pathway ER

Lysosome

Phagosome

Peptide fragments

Endocytosis of extracellular protein

CD4+ T cell

Invariant chain (Ii)

Class II MHC

FIG 9.28 Only specialized cells are able to obtain extracellular antigen for processing and presentation in association with major histocompatibility complex (MHC) class II protein. These cells are primarily dendritic cells, macrophages, and B cells. The antigen is first engulfed into a vesicle called a phagosome, which fuses with a lysosome. Enzymes within the phagosome break the protein into pieces. MHC II molecules are synthesized on the endoplasmic reticulum (ER) and then transported to the phagosome in a vesicle. The binding cleft of the MHC II protein is complexed with a blocking protein to prevent it from retrieving peptide before it reaches the phagosome. The phagosome and vesicle fuse, and the MHC II loses its blocking protein and picks up an antigen peptide. The complex then migrates to the cell surface and combines with the cell membrane. The MHC II–antigen complex is then displayed on the cell surface. (Redrawn from Abbas AK et al: Cellular and molecular immunology, ed 8, Philadelphia, 2015, Saunders, p 124.)

C C

Transmembrane region

Peptide

Disulfide bond

Ig domain

N

α1

N

β1

Peptide-binding cleft

α2 β2

Class II MHC

A B

FIG 9.29 Schematic (A) and ribbon (B) diagrams of the class II major histocompatibility complex (MHC) molecule. Note that the peptide-binding cleft is formed from two separate polypeptide chains, which allows the size of peptide in the pocket to be 10 to 30 amino acids. (From Abbas AK et al: Cellular and molecular immunology, ed 8, Philadelphia, 2015, Saunders, p 121.)

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and types of cytokines. These cytokines provide the “help” that T helper cells give to other cells of the immune system. For example, IL-2 activates helper and cytotoxic T cells, NK cells, and macrophages; and IFN-γ is a potent activator of macrophages. IL-2 and IFN-γ are the main cytokines secreted by TH1 cells. The cytokines secreted by TH2 cells have stimulatory effects on B cells (e.g., IL-4, IL-5, IL-13). In addition, when a B cell is serving as the antigen-presenting cell, T helper cells provide specific B-cell help through direct cell-to-cell contact by receptor proteins. The TH17 lymphocytes secrete IL-17, a cytokine that stimulates neutrophil recruitment and prompts fibroblasts and other cells to secrete more proinflammatory signals. TFH lymphocytes reside in the lymph node follicles where they produce cytokines that stimulate B cells. TREG

being presented (Fig. 9.30). Binding of the TCR to its corresponding antigen generates a signaling cascade in the cytoplasm of the T helper cell. The TCR is linked to this signaling cascade through another protein called CD3. Stimulation of CD3 results in the activation of enzymes (kinases) in the cytoplasm that mediate the production of two second messengers: inositol trisphosphate (IP3) and diacylglycerol (DAG) (see Chapter 3). Inositol trisphosphate initiates a rise in the concentration of intracellular calcium ions, which also act as second messengers to change cell behavior. Other protein kinases turn on the genes for cytokines (e.g., IL-2, IFN-γ, and others), IL-2 receptors, and other cell surface proteins. As previously mentioned, the subtypes of T helper cells (i.e., TH1, TH2, TH17, TFH, and TREG) secrete somewhat different amounts

Antigen-presenting cell

CD4

CD3

PIP2

DAG

Protein kinase C RAS activationIP3

MHC II

TCR

Helper T cell

�

PLCγ

Ca2+

NFAT

Activation of gene transcription

AP-1NF�B

IL-2 receptors Proliferation of cloneIL-2

FIG 9.30 T helper cells can recognize and bind antigen in association with major histocompatibility complex (MHC) class II molecules. The T-cell receptor (TCR) on the T helper cell binds to the antigen, and the CD4 protein recognizes the MHC class II protein. Binding is highly specific because the TCR must match the antigen fragment precisely. Once binding is achieved, CD3 and ζ proteins associated with the TCR are activated to initiate intracellular enzyme cascades. Major signaling pathways in activated T cells are shown. These ultimately result in activity of transcription factors and changes in gene activity. AP-1, Activation protein-1; DAG, diacylglycerol; IP3, inositol 1,4,5-trisphosphate; NFAT, nuclear factor of activated T cells; NFκB, nuclear factor kappa B; PIP2, phosphatidylinositol 4,5-bisphosphate; PLCγ, phospholipase C-γ.

CHAPTER 9 Inflammation and Immunity 181

complementary CD95 proteins (Fas) found on the surface of target cells. Normal, healthy cells do not express CD95 and are not recognized by cytotoxic cells. Binding of the CD95L to CD95 triggers programmed cell death (apoptosis) of the target cell (see Fig. 9.32). This system is thought to be particularly important in culling senescent cells and self-reactive lymphocytes.

MECHANISMS OF HUMORAL IMMUNITY B cells are responsible for antibody-mediated (humoral) immunity. B cells have two major subpopulations: memory cells and plasma cells. Memory B cells contain antigen receptors and function in a manner similar to memory T cells. In other words, memory of exposure to an antigen is stored in a clone of memory B cells. When exposed to the same type of antigen in the future, these memory B cells are able to respond rapidly with appropriate antibodies.

Some B cells differentiate into short-lived antibody-producing factories called plasma cells. All of the plasma cells in a clone secrete antibodies with identical antigen-binding specificity (monoclonal antibody). The secreted antibodies circulate in the blood and body fluids and bind specifically to the antigen that triggered their production. Once antigen is cleared, the population of plasma cells declines and the antibody concentration (titer) falls. However, some long-lived plasma cells migrate to the bone marrow where they continue to secrete a level of antibody sufficient to provide immediate protection upon the next exposure to the same antigen.

Antigen Recognition by B Cells During their development in the bone marrow, B cells begin to express BCRs on their cell surfaces. The structure of the antigen-binding area on the BCR is randomly determined in a manner similar to that described for TCRs. Each BCR is coded for by two distinct types of genes: one for the variable region, which makes up the antigen-binding site; and one for the constant region, which is essentially the same for all antibodies of a given class (Fig. 9.33). The structure of the BCR bound to the B-cell

lymphocytes secrete inhibitory cytokines such as IL-10 and TGF-β to help control inflammation and immune reactions to prevent excessive tissue damage (Fig. 9.31).

Cytotoxic T Cells (CD8+) Cytotoxic T cells recognize antigen displayed in association with MHC class I protein. The CD8 protein is needed to facilitate binding to the MHC I, whereas the TCR specifically recognizes the presented antigen (Fig. 9.32). Binding of the TCR to its corresponding antigen triggers a number of responses in the cytotoxic T cell. This process is similar to that described for T helper cells and involves signal transduction through CD3 proteins. Antigen binding by cytotoxic T cells is not sufficient to activate them. Cytotoxic T cells also require costimulation by IL-2 cytokines. IL-2 is secreted primarily by activated T helper cells (TH1). Thus cytotoxic T cells require cytokine “help” before they proliferate effectively. Cytokines are generally not enough to induce significant proliferation of target cells unless other coactivators are also presented by target cells (see Fig. 9.32). Once activated, cytotoxic T cells proliferate into memory cells as well as effector cells. Effector cells accomplish their cytotoxic functions in two ways: through perforins and through CD95.

Perforins are proteins manufactured in the cytotoxic T cell and stored in granules (vesicles) within the cytoplasm. A number of pro- teolytic enzymes (granzymes) are located in the granules along with the perforins. Binding to the target cell causes the granules to migrate to the contact site, where they are released onto the target cell membrane. The perforins assemble into pores, which then allow the granzymes to move into the target cell. Granzymes degrade DNA and trigger target cell death (apoptosis).

Perforins function in a similar manner to the complement membrane attack complex previously described. It is not entirely clear how the cytotoxic T cell manages to escape injury in this process. Presumably, the perforins and granzymes are focused on the target cell in some controlled manner.

The CD95 protein on cytotoxic T cells is called the CD95 ligand (CD95L) or the Fas ligand (FasL). It can bind specifically to

T helper cell

TH1

IFN� IL17IL4 IL5 IL13

IL4 IL21

TGF β IL10

TH17 TFH TREGTH2

CD4

FIG 9.31 Subtypes of CD4 T cells have different functions, including different cytokine production and secretion.

182 UNIT III Defense

surface is similar to the structure of IgM. Rearrangement, recombination, selective splicing, and random mutations of variable-region genes allow for great diversity of BCR-binding specificities. The potential number of different BCR structures is enormous. Some of these combinations are unsuitable for BCR assembly, and it has been estimated that a typical human B-cell population can recognize approximately 1011 different antigenic epitopes. As is the case with T cells, useful B cells—ones activated by antigen—will be preserved in the body, whereas B cells that encounter no antigen will not proliferate. Binding of an antigen to the B cell results in the cross-linking of two surface BCR proteins and initiates an intracellular cascade. These cascades activate transcription factors within the B cell (NFκB, NFAT, AP-1) that regulate genes involved in proliferation and differentiation of the B cell (Fig. 9.34).

The growth and activity of B cells that recognize protein antigens are regulated by helper T cells. Binding of antigen to the B cell’s BCR is a necessary but insufficient stimulus to produce an effective B-cell clone in most cases. To be effectively activated, the B cell must engulf some of the antigen, process it, and present it to T helper cells. This activity will initiate cell-to-cell contact between the B cell and its complementary T-cell helper. A number of receptor interactions bind the T cells and B cells together, in addition to the main MHC II–TCR interaction, and include CD80–CD28 and CD154–CD40 (Fig. 9.35). These cell-to-cell binding interactions stimulate intracellular signaling pathways in the B cell (and T helper cell) that promote clonal expansion and differentiation. B cells also require certain cytokines to proliferate and begin antibody synthesis. B cells are quite dependent on T-cell help during the initial exposure to antigen (primary response), but less so on subsequent exposures. Some types of B cells have BCRs that bind nonprotein antigens, such as bacterial carbohydrates and lipids. Because T cells only recognize peptides, these types of B-cell responses are T-cell

�

Perforins and granzymes

Cytotoxic T cell Virally

infected cell

Cell lysis or apoptosis

LFA-1

TCR

CD2

CD3

CD28

FasL Fas Cell apoptosis

ICAM-1

Class I MHC

LFA-3 Peptide

B7-1/ B7-2

FIG 9.32 Cytotoxic T cells are able to recognize and bind antigen in association with major histocompatibility complex (MHC) class I molecules. The T-cell receptor on the cytotoxic T cell binds to the antigen, and the CD8 protein recognizes the MHC I protein. Binding is specific. Binding of a cytotoxic T cell to its target stimulates granules containing perforin and granzymes to migrate to the cell contact site. Perforins then assemble into pores on the target cell, through which the granzymes can enter the target cell cytoplasm. The granzymes interrupt the cellular DNA and trigger apoptosis. FasL, Fas ligand (CD95L); ICAM, intercellular adhesion molecule; LFA, leukocyte function–associated antigen; TCR, T-cell receptor.

DNA

V1

C4 C4C1 C1

C2

H H

C2

C3 C3

V1 C4 C1 C2H C3

V1V2

V2

V2

FIG 9.33 Two major classes of genes are responsible for coding for the variable (V) and constant (C) regions of an antibody. Variable genes code for the antibody region that binds to antigen. Constant genes form the stem of the antibody and are the same for any antibody of a given class.

CHAPTER 9 Inflammation and Immunity 183

Peptide antigen

Protein kinase C RAS activationIP3

B cell

Ca2+

NFAT

Activation of gene transcription

AP-1NF�B

Differentiation into memory cells and plasma cells

Proliferation of clone

PIP2

DAG

PLCγ

FIG 9.34 Major signaling pathways in B cells. Cross-linking of two surface B-cell receptors initiates intracellular pathways that subsequently activate several transcription factors leading to altered gene activity. AP-1, Activation protein-1; DAG, diacylglycerol; IP3, inositol 1,4,5-trisphosphate; NFAT, nuclear factor of activated T cells; NFκB, nuclear factor kappa B; PIP2, phosphatidylinositol 4,5-bisphosphate; PLCγ, phospholipase C-γ.

independent. Other costimulatory signals, such as the complement fragment C3d on the antigen, may provide the necessary costimulation to achieve a B-cell response and antibody production. It is doubtful that memory cells are formed in this process (Fig. 9.36).

ANTIBODY STRUCTURE Each antibody (immunoglobulin) molecule contains two identical light polypeptide chains joined by disulfide bonds to two identical heavy polypeptide chains. The geometry of the relationship between the heavy (H) and light (L) chains forms a Y-like structure. The H chains form the stem of the Y, and the L chains are on the outside of the arms of the Y. The antigen-binding end of the antibody is often called Fab (antigen-binding fragment), whereas the stem is called Fc (constant fragment). It is the structure of the constant fragment that determines the antibody class.

Antibodies are differentiated into five classes: IgG, IgM, IgA, IgD, and IgE. The structure and properties of the immunoglobulin classes

are listed in Table 9.4. IgG and IgE circulate as single molecules or monomers; IgA is a dimer (two antibodies joined together); and IgM consists of five antibody molecules joined together to form a pentamer. IgD is found mainly on the B-cell plasma membrane and does not circulate in significant quantity. IgD is thought to participate in signal transduction across the B-cell membrane along with the BCR. Different antibody classes serve different immune functions in the body.

IgG, the most common type of immunoglobulin, accounts for 75% to 80% of all immunoglobulins. It is found in nearly equal proportions in the intravascular and interstitial compartments and has a long half-life of about 3 weeks. IgG is the smallest of the immunoglobulins and can more easily escape the bloodstream to enter the interstitial fluid sur- rounding tissues.

IgM accounts for about 10% of circulating immunoglobulins and is predominantly found in the intravascular pool. Its large pentamer structure prevents it from migrating through the capillary wall. IgM has a half-life of 10 days. It is the first immunoglobulin to be produced on exposure to antigens or after immunization and is the major antibody

184 UNIT III Defense

IgA is produced by plasma cells located in the tissue under the skin and mucous membranes. IgA is primarily found in saliva, tears, tra- cheobronchial secretions, colostrum, breast milk, and gastrointestinal and genitourinary secretions. Transport of IgA into secretions is facilitated by binding to a secretory component produced by epithelial cells. This

found on B-cell surfaces. IgM is the antibody class that works best to activate complement, which is important for cytotoxic functions in the immune system. Only one molecule of IgM is needed to activate complement, whereas two molecules of IgG are needed to activate complement.

Antigen presentation to helper T cell

CD40 CD40

CD28CD80

CD28CD80

Activation of T helper to release cytokines

Cytokines

Helper T cell

B cell CD154 CD154

FIG 9.35 Activation of a B cell requires T helper cell “help.” This help is given through a number of cell-to-cell interactions via receptors, as well as through the secretion of cytokines that stimulate B-cell growth and differentiation.

CR2 CD19

CD81

Igα Igβ

B-cell activation

Complement activation

Recognition by B cells

Signals from Ig and CR2

complex

Bound C3d

Microbe

IgM

P

P

P

P

FIG 9.36 In response to nonprotein antigens (T-cell independent), B cells can be activated by complement opsonins on the microbial antigen. The complement–receptor (CR) interaction provides a costimulatory signal to the B-cell receptor–antigen signal. (Redrawn from Abbas AK et al: Cellular and molecular immunology, ed 8, Philadelphia, 2015, Saunders, p 159.)

CHAPTER 9 Inflammation and Immunity 185

identified in the serum. IgE has a half-life of 2 days. It has a role in immunity against helminthic parasites (worms) and is responsible for initiating inflammatory and allergic reactions (e.g., asthma, hay fever). IgE functions as a signaling molecule and causes mast cell degranulation when antigen is detected at the mast cell surface (see Chapter 10).

Class Switching and Affinity Maturation During the course of an antibody response, the class of antibody manufactured by a particular B cell usually changes. The antigen-binding

complex is called secretory IgA (Fig. 9.37). The half-life of IgA is about 6 days.

IgD is found in trace amounts in the serum (1%) and is located primarily on the membranes of B cells along with IgM. IgD has a half-life of 3 days. IgD functions as a cellular antigen receptor acting to stimulate the B cell to multiply, differentiate, and secrete other specific immunoglobulins.

IgE is found bound by its Fc tail to receptors on the surface of basophils and mast cells (Fig. 9.38). Only trace amounts of IgE are

TABLE 9.4 Diagram and Properties of Immunoglobulin Classes

IgG IgM IgA IgD IgE

Property

Half-life (days) 23–25 5 6 3 2.5 Percent total immunoglobulin 80 6 13 0–1 0.002 Molecular weight (daltons) 146,000 900,000 160,000 184,000 200,000 Complement fixation ++ +++ − − − Placental transfer +++ − − − − Receptor for macrophage +++ − − − − Reaction with staph protein A +++ − − − − Passive cutaneous anaphylaxis +++ − − − + Transported across epithelium − Occasionally ABO

isoaggulutinins, rheumatoid factor

+ − − Prominent antibody activity Anti-Rh against

infections Against

infections Binds to B cells in

presence of IgM Mast cell sensitization,

cytophilic antibody skin sensitizing antibody

Cell-Binding Functions Mononuclear cells + − − − ?/+ Neutrophils + − + − − Mast cells/basophils − − − − +++ T cells/B cells + + + + + Platelets + + − − ?

Data from Abbas AK: Cellular and molecular immunology, ed 8, Philadelphia, 2015, Saunders.

+ IgA Secretory

component

Secretory IgA

FIG 9.37 IgA is often combined with a protein called secretory component, which helps bind two IgA molecules together at their Fc ends.

186 UNIT III Defense

For example, IFN-γ promotes IgG production, IL-4 promotes IgE production, and transforming growth factor-β (TGF-β) promotes IgA production (Fig. 9.39).

Knowledge about the normal progression of class switching may be helpful in determining whether an infectious process is acute or chronic. For example, a person newly infected with hepatitis B virus would be expected to have primarily IgM antihepatitis B antibodies, whereas in chronic or previous infection, B cells would switch class to produce mainly IgG. The relative concentrations of antihepatitis B IgM and IgG can help identify the time of onset of the infection.

Over the course of a B-cell antibody response, the affinity with which the antibodies bind to antigen often increases. This is thought to occur because of a process called affinity maturation during which B cells undergo a hypermutation response, producing random changes in the antigen-binding pocket of the BCR. Those that bind antigen most avidly are stimulated to proliferate to a greater extent. Thus the antibodies formed later in an immune response are more efficient in binding antigen at lower and lower concentrations. Affinity maturation occurs in specialized germinal centers in the lymph nodes.

Antibody Functions Antibodies function in a number of ways to enhance the localization and removal of antigens from the body. These functions can generally be summarized as precipitation, agglutination, neutralization, opsoniza- tion, and complement activation. Precipitation and agglutination occur because each arm of the immunoglobulin Y structure can bind an antigenic epitope. This structure allows the antibodies and antigens to bind together into large insoluble complexes that precipitate out of body fluids (Fig. 9.40). Agglutination refers to the same process as applied to cellular antigens rather than soluble antigens. It is efficient for phagocytic cells to find the large complexes and clear them from the system.

site does not change significantly and remains specific for the particular antigen that initiated the response. To switch class, the B cell selects different constant region genes to splice to the antigen-binding fragment. Thus most B cells begin by using genes that code for IgM and IgD. Then the B cell switches to produce IgG, IgE, or IgA. The triggers that determine the class of antibody a particular B cell will produce are not completely understood. Some cytokines have a role in class switching.

Fc�Rl

Antigen

Plasma cell

Mast cell

IgE

FIG 9.38 Mast cells bind IgE antibody with their Fc receptors (FcεRI) and display the IgE on the cell surface, where they are available to bind antigens.

IgM+

B cell

IgG subclasses (IgG1, IgG3) IgE IgA

Isotype switching

IgM

Activated B cell

CD40

Helper T cell

CD40 ligand

CD28

B7-1, B7-2

IL-4 IFN-�

Mucosal tissues; cytokines

(e.g., TGF-�)

FIG 9.39 Activated B cells undergo class switching from IgM to IgG, IgE, or IgA. Class switching is influenced by the presence of specific cytokines. IFN, Interferon; IL, interleukin; TGF, transforming growth factor. (Redrawn from Abbas AK et al: Cellular and molecular immunology, ed 8, Philadelphia, 2015, Saunders, p 252.)

CHAPTER 9 Inflammation and Immunity 187

Phagocyte

Fc receptor

Ag Ag

Ag

Ag Ag

FIG 9.40 Large antigen (Ag)–antibody complexes tend to precipitate out of solution, which makes it easier for phagocytic cells to find and eliminate the antigens.

Antibodies can function as antitoxins by neutralizing bacterial toxin. This role is accomplished by binding the toxins before they can interact with cells or by covering the active portions of the toxin and inactivating it. Some antibodies are effective opsonins. They coat the foreign antigen and thereby make it more recognizable to phagocytic cells. Macrophages, neutrophils, eosinophils, and NK cells have receptors for the Fc ends of the antibodies, which help them bind to opsonized antigens. Antibodies thus make the innate phagocytic processes more efficient. Antibodies (IgG and IgM) bound to foreign antigens on cell membranes also can activate the complement cascade and trigger the release of chemotaxins and inflammatory mediators and the formation of the membrane attack complex.

PASSIVE AND ACTIVE IMMUNITY Immunity is a state of resistance against infection from a particular pathogen. Immunity is provided primarily by adequate levels of circulat- ing antibodies. Specific serum antibody concentrations can be measured by a blood test called an antibody titer. A sufficiently high antibody titer confers immunity by removing pathogens from the body before they cause signs and symptoms of illness. Immunity can be achieved passively or actively.

Passive Immunity Passive immunity involves the transfer of plasma (sera) containing preformed antibodies against a specific antigen from a protected or immunized person to an unprotected or nonimmunized person. As a treatment, this is indicated in the following situations: (1) when B-cell immunodeficiency exists; (2) when highly susceptible persons are exposed to a disease without adequate time for active immunization; and (3) when antibody injection may alleviate or suppress the effects of an antigenic toxin.

Passive transfer of antibodies can occur in a variety of ways. In the fetus, certain maternal IgG antibodies can cross the placental barrier. Most of the time these antibodies are beneficial and assist the newborn in resisting pathogens. However, in some cases these antibodies can be

damaging to the fetus, as occurs in hemolytic disease of the newborn. In this disorder, maternal antibodies bind to and lyse fetal red blood cells (see Chapters 10 and 13).

Antibody, complement, and macrophage function is deficient at birth. Newborns who are breast fed may have improved immune function. Newborns receive IgA antibodies through breast milk. The infant’s immature gastrointestinal tract and low proteolytic enzyme activity do not destroy all protein, which allows some of the IgA antibodies to be absorbed. These antibodies assist the infant in defending against bacterial and viral infections during infancy. It has been hypothesized by some researchers that IgA antibodies in breast milk may modify the ways that proteins cross the infant’s highly permeable intestinal mucosa and help prevent food allergies in later life (see Pediatric Consideration box).

Another method of passive immunity, called serotherapy, involves direct injection of antibodies into an unprotected person. The unpro- tected individual can receive a variety of substances, including immune globulin (human) such as IgG; specific immune globulins like hepatitis B immune globulin (human) or rabies immune globulin (human); plasma containing all human antibodies; or animal antibodies such as diphtheria antitoxin, tetanus antitoxin, botulism antitoxin, and antirabies serum.

Human immune globulin contains mostly IgG with traces of IgA and IgM. It is a sterile, concentrated protein solution that contains antibodies from the pooled plasma of many adults. It can be administered intramuscularly or intravenously, depending on the product. Human immune globulins may be used as prophylaxis against hepatitis B and as therapy for the following conditions: antibody deficiency disorders, pediatric acquired immunodeficiency syndrome, and hypogammaglobu- linemia after bone marrow transplantation.

Animal antibodies are given in specific situations only when necessary because of significant allergic risks with animal sera. Patients who have specific animal allergies or a history of asthma, allergic rhinitis, or other allergies are highly susceptible to serum sickness, anaphylaxis, or acute febrile reactions. Serum sickness occurs when antibodies bind to foreign proteins in the injected sera, forming immune complexes that precipitate into capillaries and joints and cause inflammation. Animal antibodies may be given to ameliorate toxins or venoms, such as those associated with botulism, diphtheria, rabies, tetanus, and snake and spider bites.

Active Immunity Active immunity confers a protected state attributable to the body’s immune response as a result of active infection or immunization. The development of active immunity requires the maturation and maintenance of memory B cells. On second exposure to antigen, the antibody response is much greater and more rapid (Fig. 9.41). Expo- sure to antigen can be achieved through active infection or through immunization. The immune system must be exposed to the antigen at a sufficient dose for an adequate length of time to stimulate an immune response.

Immunization tricks the immune system into responding to a perceived infection. Vaccines contain altered microorganisms or toxins that retain their ability to stimulate the immune system (antigenic properties) but do not have pathogenic properties. Vaccines can contain live and attenuated (altered) or killed infectious agents.

Vaccines that contain live, altered viruses or bacteria cause active infection but little injury to the vaccinated individual. These vaccines mimic a natural immune response, activating B and T cells, and provide good humoral and cellular immunity with longer-lasting memory and often lifetime immunity. Examples of vaccines registered in the United States are listed in Box 9.1.

188 UNIT III Defense

IgG

IgG

S e ru

m a

n tib

o d y

co n ce

n tr

a tio

n

IgM IgM

10 3 Secondary stimulus

Primary stimulus

PRIMARY RESPONSE

SECONDARY RESPONSE

Time (days)

FIG 9.41 Time phases in the immune response. The primary response takes much longer to develop and declines rapidly. On second exposure, a much quicker and greater antibody response is achieved.

B cells differentiate slower in infants

Maternal antibodies passed on to newborn

Thymus

Quantity and function of T lymphocytes decreased

IgM is produced at birth but specificity is decreased

Limited response to viral, fungal, and bacterial antigens

Inflammatory response to infection is immature

IgA, IgD, IgE production gradual

Maternal IgG passed through placenta and human milk

Maternal IgG decreased; limited replacement occurs

IgA present in colostrum

The immune system is immature in an infant. Infants generally do not produce immunoglobulin (Ig) until the beginning of the second month of life, and then production is slow (Hockenberry and Wilson, 2011). IgM is produced at birth, but specificity is decreased, limiting the infant’s ability to fight some antigens. IgM reaches adult levels by 9 to 12 months. IgA, IgD, and IgE begin gradual production in the second month of life and reach adult levels around early childhood.

Infants rely on maternal antibodies for production until their own immune system can mature. Maternal IgG is passed through the placenta and breast milk and for the first 3 months provides protection to the infant from antigens to which the mother has been exposed. IgG levels decline after 4 months and remain low until 6 months of age. Forty percent of infants achieve adult levels

of IgG by 1 year of age, with the remaining reaching adult IgG levels by 4 years of age. IgA is present in the colostrum and believed to protect the infant’s gastrointestinal tract until more IgA can be produced.

The thymus is large in infants and decreases in size over childhood. By the end of adolescence, the thymus shrivels and its function declines. The infant’s immune response is immature, resulting in a limited response to viral, fungal, and bacterial antigens.

Reference Hockenberry MJ, Wilson D: Wong’s nursing care of infants and children, ed 8,

St Louis, 2011, Mosby.

PEDIATRIC CONSIDERATIONS Changes in the Immune System in Infants

CHAPTER 9 Inflammation and Immunity 189

Data from www.fda.gov/BiologicsBloodVaccines/Vaccines/ ApprovedProducts/ucm093833.htm.

Adenovirus Type 4 and Type 7 Vaccine, Live, Oral Anthrax Vaccine Adsorbed BCG Vaccine Diphtheria and Tetanus Toxoids Adsorbed Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine Adsorbed,

Hepatitis B (recombinant) and Inactivated Poliovirus Vaccine Combined Haemophilus b Conjugate Vaccine (plus various combinations including:

Diphtheria, Meningococcal Protein Conjugate, Tetanus Toxoid Conjugate, and Hepatitis B)

Hepatitis A Vaccine, Inactivated Hepatitis B Vaccine (Recombinant) Human Papillomavirus Quadrivalent (Types 6, 11, 16, 18) Recombinant Vaccine Human Papillomavirus Bivalent (Types 16, 18) and 9-Valent Influenza Virus Vaccine (Various including Types A, H1N1, B, H5N1) Japanese Encephalitis Virus Vaccine Inactivated Measles Virus Vaccine, Live Measles and Mumps Virus Vaccine, Live Measles, Mumps, and Rubella Virus Vaccine, Live Measles, Mumps, Rubella, and Varicella Virus Vaccine, Live Meningococcal Polysaccharide Vaccine, Groups A, C, Y, and W-135 Combined Pneumococcal Vaccine, Polyvalent Pneumococcal 7-Valent Conjugate Vaccine Pneumococcal 13-Valent Conjugate Vaccine Poliovirus Vaccine Inactivated Rabies Vaccine Rotavirus Vaccine, Live, Oral, Pentavalent Smallpox (Vaccinia) Vaccine, Live Tetanus and Diphtheria Toxoids Adsorbed for Adult Use Tetanus Toxoid Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine

Adsorbed Typhoid Vaccine Live Oral Ty21a Typhoid Vi Polysaccharide Vaccine Varicella Virus Vaccine Live Yellow Fever Vaccine Zoster Vaccine, Live

BOX 9.1 Selected Vaccines Available for Immunization in the United States

KEY POINTS • Specific immunity refers to functions of B and T lymphocytes. Each lymphocyte

recognizes and reacts to only one particular antigen. On initial exposure to an antigen, lymphocytes undergo clonal expansion; consequently, many lymphocytes are distributed throughout the body to recognize and react to that particular antigen. These cells are called memory cells. Subsequent exposure results in a much faster and larger lymphocyte response.

• T cells, which mature in the thymus, have two major subgroups: T helper cells and cytotoxic T cells. T helper cells perform a central role in specific immunity. Activation of T helper cells results in secretion of the cytokines necessary for clonal expansion of T and B lymphocytes. Cytotoxic T cells locate and lyse abnormal cells through the actions of perforins.

• T lymphocytes are able to bind antigens only when they are displayed on the surface of cells. Cytotoxic T cells (CD8+) react to cells that have foreign MHC class I proteins on their surface. T helper cells (CD4+) bind to cells that have MHC class II proteins on their surface. MHC class II proteins are found on antigen-presenting cells (B cells, dendritic cells, and macrophages). These cells engulf foreign antigens and combine the antigens with MHC class II proteins on their cell surface.

• B and T cell functions are interdependent. T cells cannot respond to soluble antigens. B cells can process free antigen and present it to T cells. On first exposure, B cells are minimally activated by antigen unless they are stimulated by cytokines and coreceptors from T cells.

• B lymphocytes mature in bone marrow and lymph tissue. B cells have receptors on their surfaces that can bind antigens. Each B cell binds only one particular antigen. With appropriate T helper cell “help,” antigen binding causes the B cell to divide (clonal expansion). Some of the daughter cells become plasma cells, which actively produce and secrete antibodies. Other daughter cells (memory cells) resemble the original cell and are distributed in lymph throughout the body. On subsequent exposure to the antigen, antibody production is rapid.

• Antibodies are proteins that specifically bind a particular antigen. Antibodies have several functions, including precipitation, agglutination, neutralization, opsonization, and complement activation.

• The five major antibody classes are IgG, IgM, IgA, IgD, and IgE. Antibody class is determined by the structure of the Fc portion. IgG is the most prevalent antibody class (75%). IgM is the first kind to be produced on antigen exposure. IgA is found primarily in body secretions. IgD is present on the B-cell membrane and functions in signal transduction. IgE binds to basophil and mast cell membranes and mediates inflammation and allergy.

• Administration of preformed antibodies confers passive immunity. Passive immunity provides immediate but temporary protection. Active immunity occurs when individuals are exposed to antigen that stimulates their own lymphocytes to produce memory cells. Active immunity confers long-term protection but may take several weeks to develop.

INTEGRATED FUNCTION AND REGULATION OF THE IMMUNE SYSTEM

The innate and adaptive cells of the immune system work interdepen- dently to protect the host from foreign antigens. Efficient interdependent function depends on a complex communication network that allows coordination of various immune components. One of the reasons that the immune system uses such a complex communication system is to ensure that normal healthy tissue is not injured. The destructive powers of the immune system must be tightly regulated to avoid undue tissue damage. These regulatory controls can be affected by aging and disease. The effects of aging on immune function are described in the box Geriatric Considerations: Changes in the Immune System. In the

following sections, major events in the immune response to a new antigen are summarized and mechanisms of immune regulation are described.

INTEGRATED RESPONSE TO MICROBIAL ANTIGEN A new microbial antigen entering the body through the skin or mucous membranes will generally encounter tissue macrophages and dendritic cells stationed in strategic locations in the body as part of the mono- nuclear phagocyte system. Macrophages initiate activity of both innate and specific immune components (Fig. 9.42). First, activated macrophages release cytokines that initiate inflammation and chemotaxis. Some of these cytokines (TNF-α, IL-1) induce capillary endothelial cells to express selectins and integrin ligands that help circulating leukocytes adhere to the capillary wall (margination) and then move into the tissue locations of antigens (emigration). Neutrophils, macrophages, and NK cells are attracted to the infected area by chemotactic factors, some of which are released by macrophages, whereas others are products of the

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to the tissue find their targets through innate receptors on their cell surfaces. Thus they are as effective on first exposure to an antigen as they are on subsequent exposures. These receptors bind to complement opsonins and molecules expressed on microbes such as lipopolysaccharide and mannose. NK cells release cytotoxins onto their targets; macrophages and neutrophils phagocytose and digest their targets.

Dendritic cells and macrophages ingest protein antigens to process and present them to T helper cells in association with MHC class II proteins. Dendritic cells move from the tissue and travel to the T-cell zones of lymph nodes. Activation of T helper cells results in the secretion of a variety of cytokines that boost the growth and activity of many immune cells, including macrophages, neutrophils, NK cells, cytotoxic and T helper cells, and B cells. Some of the cytokines produced by

complement cascade and tissue injury. The complement cascade is activated by the alternative pathway on primary exposure to an antigen. Complement fragments C3a and C5a are potent inflammatory agents. Complement activation also results in the formation of membrane attack complexes that directly lyse cellular antigens.

Tissue injury associated with the infectious process also activates both the coagulation cascade, which forms a fibrin meshwork to help entrap and localize the agent, and the kinin system, which promotes vasodilation to increase blood flow to the area. A number of other vasodilatory chemicals may be released from mast cells in the area when they degranulate. These inflammatory chemicals lead to the classic manifestations of inflammation: warmth, swelling, redness, pain, and loss of function. Neutrophils, macrophages, and NK cells that emigrate

Antigen

Inflammatory cytokines

Acute phase proteins from liver

Cytokine "help"

Dendritic cell

Cytokine

"help"

Inflammation

Chemotaxis

Complement activation

NK cell Antigen lysis

Antibody secretion

Helper T cell

B cell

BCR

Neutrophil Capillary

Macrophage

Stimulates WBC production at marrow

T cell "help"

Fc receptor

Fc receptor

MHC II

TCR

CD4

MHC II TCR

CD4

FIG 9.42 Diagram showing the integrated function of a number of immune components. Note that the macrophage is at the center of many immune functions, including chemotaxis and inflammation, presentation of antigen to T cells, and phagocytosis of antibody–antigen complexes. BCR, B-cell receptor; MHC, major histocompatibility complex; NK, natural killer; TCR, T-cell receptor; WBC, white blood cell.

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Variable response of B cells to antigens

Decreased antibody response

Thymus decreases in weight, size, and function

Decreased maturation of lymphocytes (T cells)

Decreased cell-mediated immunity

Decreased response to viral, fungal, and bacterial antigens

Decreased speed of repair of tissue damage

Change in cellular composition of spleen and lymph nodes

Increased production of autoantibodies

In the elderly, immune system function is altered with a decreased ability to respond to antigenic stimulation. The elderly are able to respond to infections with previously produced “remembered” antibodies. However, they are less able to respond to new antigens. As a result of these changes, there is decreased speed of repair of tissue damage and increased vulnerability to disease. The cells of the immune system in elderly persons are not able to proliferate or reproduce as effectively as those in younger persons. Although the total number of T cells remains the same, T-cell function is decreased. T cells are less able to

proliferate and have decreased cytotoxicity. Antibody production also decreases, especially antibodies such as IgG. There is also a rise in autoantibody production, which may influence the increase in autoimmune disease in the elderly. Thymus size decreases after puberty, causing a decline in thymic hormone production, decreased T-cell differentiation, and reduced T-cell–related B-cell differen- tiation. Usually thymic hormone secretions stop after age 60 years. However, the role of thymus involution in elderly immune system changes is currently uncertain.

GERIATRIC CONSIDERATIONS Changes in the Immune System

activated T cells and macrophages stimulate stem cells in the bone marrow to produce more WBCs (neutrophilia). Other cytokines affect the brain (inducing fever, lethargy, and anorexia) and the liver (producing acute phase proteins).

Meanwhile, certain B cells that encounter the antigen in the lymph nodes will have the correct BCR to bind and internalize it. Internalized antigen is then processed and presented to T helper cells in association with B-cell MHC II proteins. Complementary T helper cells then bind the B cell (via MHC II–TCR–CD4 interactions) and provide help to the B cell through the secretion of cytokines and through coreceptor- mediated second-messenger signals. B cells thus activated proliferate into a clone of cells, with some becoming memory cells and others becoming plasma cells. Plasma cells synthesize and secrete antibodies that specifically bind the antigen. Significant antibody production takes 10 to 14 days to occur, and the infected individual may have signs and symptoms of illness during this time.

Antibodies enhance the function of innate phagocytic cells by col- lecting antigen into large complexes that are easier for nonspecific cells to locate and phagocytose. Activated T helper cells also secrete cytokines such as IL-2 and IFN-γ, which enhance the effectiveness of macrophages. After the antigen is cleared from the body, macrophages perform clean-up functions to remove inflammatory debris and dead neutrophils from the tissue. Macrophages also secrete enzymes and growth factors that stimulate tissue healing.

After the primary infection, B and T memory cells populate the body in much larger numbers and can mount an effective immune response quickly on second exposure. The individual then has immunity for the particular pathogen because the antigen will usually be cleared from the system before significant illness occurs.

INTEGRATED RESPONSE TO VIRAL ANTIGEN If the infectious agent is a virus, the sequence of events is somewhat different. Virally infected cells initiate cytotoxic T-cell activity, which serves to kill the infected cells. NK cells are important for detecting and destroying virally infected cells that have down-regulated their MHC I proteins, making themselves invisible to cytotoxic T cells. Helper T-cell responses and B-cell production of antibody to the virus occur by the processes previously described. However, neutrophils are less important in the response to viral infection.

Virally infected cells initiate a number of mechanisms to disrupt viral replication and prevent spread of viruses to other cells. Viral components such as viral double-stranded RNA or viral DNA can be bound to pattern recognition receptors within the host cells. These internal receptors are of the Toll-like receptor family and when activated initiate the production of type I interferons (IFN-α and IFN-β). Secreted interferons bind to receptors on nearby cells and help block viral infection

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KEY POINTS • Specific and innate immune cells work together to protect the body from

foreign antigens. Macrophages and dendritic cells play a central role because they are commonly the first immune cells to encounter the antigen. Mac- rophages secrete cytokines that stimulate WBC production and help WBCs locate the area. Tissue reactions activate the clotting cascade and kinin system, which help localize the antigen and promote movement of fluid and immune cells into the tissue.

• Macrophages and dendritic cells are antigen-presenting cells that engulf and display antigen on their cell surface in association with MHC class II proteins. T helper cells are specifically activated by these antigen-presenting cells. T helper cells secrete cytokines that promote the production of WBCs in the marrow, initiate proliferation of mature B and T cells, and stimulate the phagocytic potential of macrophages and neutrophils.

• B-cell proliferation and antibody secretion usually require T cell help. B cells internalize and present antigen to T cells, which then stimulate B-cell proliferation. B cells secrete antibodies that help phagocytic cells localize and destroy antigens.

• The immune response to primary exposure is slow and often insufficient to prevent illness. Memory cells that develop during primary exposure can mount a more effective response on subsequent exposure and usually prevent manifestations of illness.

• T and B lymphocytes must be tolerant to self. T lymphocytes capable of reacting with self tissue are thought to be destroyed or permanently inactivated during development in the thymus. One theory suggests that lymphocytes must come in contact with all self antigens during development and those that do not specifically bind self antigens are allowed to survive.

• B cells are subject to careful regulation by T helper cells and by negative feedback from high concentrations of circulating antigen–antibody complexes.

• Mechanisms to inhibit and control the immune response include activation of regulatory T-cell cytokines, complement inhibitors, circulating antiproteases, and antioxidants as well as degradation of inflammatory mediators.

C1. Other portions of the complement system are regulated by other binding proteins (e.g., factor I, factor H, and S protein). S protein is of particular importance. It prevents the complement membrane attack complex from attaching to and lysing cell membranes.

Protease inhibitors synthesized by the liver, such as α1-antitrypsin, help reduce excessive protein destruction by inhibiting destructive enzymes released from neutrophils.

The neuroendocrine system also has a role in immune regulation. Immune cells have receptors for glucocorticoid hormones and a number of neuropeptides, including enkephalins, endorphins, adrenocorticotropic hormone, oxytocin, somatostatin, and substance P. It is a well-known phenomenon that stress and depression can lead to reduced immune function. Some of these hormones are believed to be responsible for this effect. The immune system also affects the nervous system through secreted cytokines such as IL-1 and TNF-α, which induce sleep and malaise.

One of the most important mechanisms of terminating an immune reaction is the elimination of the inciting antigen. As the antigen is cleared, levels of many of the cytokines and costimulators are reduced so that “survival signals” are no longer given to lymphocyte populations and they undergo apoptosis.

Despite these complex and effective regulatory mechanisms, immune and inflammatory disorders are extremely common. Chapter 10 describes the pathophysiology of the common overreactions and underreactions of the immune system.

and replication by inhibiting protein synthesis and activation of enzymes that degrade RNA. These measures are taken to rid the body of virus even though they may result in significant cell injury and death. Virally infected cells may even express “death receptors” on their surface to alert the immune system to trigger an attack on them.

REGULATION OF IMMUNE FUNCTION The mechanisms that promote inflammation and enhance immune function are much better understood than those that negatively regulate these processes. However, the mechanisms for inactivating an immune response and keeping inflammation in check are just as important. The destructive powers of the immune system can cause severe tissue damage unless carefully controlled.

Inhibition of immune responses occurs in a number of different ways. The process of inducing tolerance to self antigens is of primary importance. Because both T and B lymphocytes produce antigen-binding receptors by a random process, generation of self-reactive lymphocytes cannot be prevented. As previously mentioned, B and T cells are subjected to a rigorous selection process as they mature in the bone marrow and thymus, respectively. Several theories have been proposed to explain how self-reactive cells are detected and eliminated. The clonal dele- tion theory suggests that cells in the thymus process and present self antigens to developing T cells. Those lymphocytes that avidly bind self antigens are triggered to initiate programmed cell death (apoptosis). There appears to be a critical time in fetal development when self antigens begin to be differentiated from foreign antigens. Before that time, antigens introduced into the fetus will be viewed as “self,” and tolerance to them will develop. By the same token, self antigens that are not presented to T cells in the thymus may be viewed as foreign. This situation may occur with certain so-called sequestered antigens, as would be found in the interior of the eye or testes. If these antigens are later released by trauma, an immune response may be directed against them.

Clonal deletion may not rid the body of all self-reactive lymphocytes; therefore many safeguards are in place to prevent their activation. A complex process of antigen processing and presentation is required before T and B cells can be effectively activated. A certain “dose” of antigen must be present to achieve an effective response. Antigen in very high concentrations appears to cripple lymphocyte responsiveness and may initiate apoptosis. Self antigens may be present in such high quantities that reactive lymphocytes are killed. Because dendritic cells, macrophages, and B cells are important antigen-presenting cells, they can exert some influence on T-cell activation by controlling the dose of antigen presented. Certain cytokines are known to influence the production of MHC proteins and can therefore alter the amount of antigen to which T cells are exposed.

B-cell activation requires a number of costimulatory signals from different sources. This complexity helps ensure that B cells will be activated appropriately. These signals include antigen binding to the BCR, T helper binding to the B-cell MHC class II protein, expression of costimulatory ligands and receptors, and secretion of cytokines that promote B-cell growth and differentiation into memory cells and plasma cells. In addition, B cells are subject to negative feedback by circulating antibodies.

Another mechanism of immune suppression is accomplished through cells that secrete inhibitory chemicals. Some subtypes of CD4 T cells may perform regulatory functions. They can inhibit immune responses by secreting immunosuppressive cytokines such as IL-10 and TGF-β.

Control of the complement, kinin, and clotting systems is achieved by a number of inhibitory binding proteins. C1 inhibitor, a glycoprotein, inhibits both Hageman factor (factor XII) and activated portions of

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Cells and tissues throughout the body participate in defense against foreign antigens. Some components of the immune system are able to react to a large number of foreign invaders upon first exposure. These innate components are essential for protecting the body while the specific immune defenses are being activated. Innate defenses include physical and biochemical barriers of the skin and mucous membranes, cells of the mononuclear phagocyte system, neutrophils, NK cells, and a large number of chemical mediators such as complement, clotting factors, kinin, and cytokines. Immunity to specific antigens is provided by B and T lymphocytes. T helper cells are important regulators of the immune

system because they secrete cytokines that enhance T-cell, B-cell, and macrophage function.

The forces of inflammation and immunity must be carefully controlled to prevent excessive tissue damage. Extensive measures are used to rid the body of self-reactive lymphocytes and to control reactions once a foreign antigen has been cleared. A well-functioning immune system not only successfully protects against foreign invaders and learns from the process so that it is even more effective on subsequent exposure, but also leaves healthy normal tissue unharmed.

S U M M A R Y

RESOURCES Immunology Abbas AK, Lichtman AH, Pillai S: Cellular and molecular immunology, ed 8,

Philadelphia, 2015, Saunders. Alberts B, et al: Molecular biology of the cell, ed 6, New York, 2015, Garland

Science, pp 1297–1342. Brostoff J, Roth D, Roitt I, editors: Immunology, ed 8, St Louis, 2012, Mosby,

pp 17–50. Dieffenbach CW, Tramont EC: Innate (general or nonspecific) host defense

mechanisms. In Bennett JE, Dolin R, Blaser MJ, editors: Mandell, Douglas, and Bennett’s principles and practice of infections diseases, ed 8, Philadelphia, 2015, Saunders, pp 26–33.

Hall JE: Resistance of the body to infection: II. Immunity and allergy. In Guyton and Hall textbook of medical physiology, ed 13, Philadelphia, 2016, Saunders.

Hanson LA, Korotkova M, Telemo E: Breast-feeding, infant formulas, and the immune system. Ann Allergy Asthma Immunol 90(6 Suppl 3):59–63, 2003.

Kasahara E, Inoue M: Cross-talk between HPA-axis-increased glucocorticoids and mitochondrial stress determines immune responses and clinical manifestations of patients with sepsis. Redox Rep 20(1):1–10, 2015.

Kumar V, Abbas A, Fausto N, Aster J: Inflammation and repair. In Kumar V, Abbas A, Fausto N, Aster J, editors: Robbins and Cotran pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, pp 69–111.

Lydyard PM: Porakishvili N: Cells, tissues and organs of the immune system. In Male D, Brostoff J, Roth D, Roitt I, editors: Immunology, ed 7, St Louis, 2006, Mosby, pp 15–45.

McNab R, Mayer-Barber K, Sher A, et al: Type I interferons in infections disease. Nat Rev Immunol 15(2):87–103, 2015.

Patton KT, Thibodeau GA: Anatomy & physiology, ed 8, St Louis, 2013, Mosby.

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10

Alterations in Immune Function Faith Young Peterson

K E Y Q U E S T I O N S • What are the potential mechanisms whereby erroneous reaction

of the immune system with self tissue leads to autoimmune diseases?

• How do type I, II, III, and IV hypersensitivity reactions differ according to the immune cell types involved and the mechanism of tissue injury?

• What are the common features of autoimmune disorders and certain types of hypersensitivity disorders?

• How are hypersensitivity disorders detected, prevented, and treated?

• How do the etiologic processes of primary and secondary immune deficiency disorders differ?

• What are the clinical features of the common immunodeficiency disorders?

C H A P T E R O U T L I N E EXCESSIVE IMMUNE RESPONSES, 195 Autoimmunity, 195

Genetic Factors, 196

Environmental Triggers, 196

Pharmacotherapies, 197

Hypersensitivity, 198 Type I Hypersensitivity, 199

Etiology, 199 Pathogenesis, 199 Clinical Manifestations, 200 Treatment, 200 Prevention, 201 Pharmacotherapeutic Prevention, 201

Type IIa Hypersensitivity, 201

Etiology and Pathogenesis, 201 Transfusion Reaction, 202 Hemolytic Disease of the Newborn, 203 Myasthenia Gravis, 204 Hyperacute Graft Rejection, 204

Type IIb Hypersensitivity, 204

Graves Disease, 204

Type III Hypersensitivity, 204

Etiology, 204 Pathogenesis, 205 Tissue Deposition, 206

Immune Complex Glomerulonephritis, 206 Systemic Lupus Erythematosus, 206

Type IV Hypersensitivity, 207

Type IVa – Granulomatous Hypersensitivity, 207 Type IVa – Tuberculin-Type Hypersensitivity, 207 Type IVa – Allergic Contact Dermatitis, 207 Type IVb – Persistent Asthma, 209 Type IVc – Stevens–Johnson Syndrome and Toxic Epidermal

Necrolysis, 209 Type IVd – Pustular Psoriasis, 209

DEFICIENT IMMUNE RESPONSES, 210 Primary Immunodeficiency Disorders, 210

B-Cell and T-Cell Combined Disorders, 210

Severe Combined Immunodeficiency Disorders, 210 Wiskott–Aldrich Syndrome, 211

T-Cell Disorders, 211

22q11.2 Deletion Syndrome (DiGeorge Syndrome), 211 Chronic Mucocutaneous Candidiasis Disease, 212

B-Cell Disorders, 212

IgA Deficiency, 212 X-Linked Agammaglobulinemia, 212 Transient Hypogammaglobulinemia, 212 Common Variable Immunodeficiency Disease, 212

Secondary Immunodeficiency Disorders, 212

http://evolve.elsevier.com/Banasik/pathophysiology/ • Review Questions and Answers • Glossary (with audio pronunciations for selected terms) • Animations

• Case Studies • Key Points Review

CHAPTER 10 Alterations in Immune Function 195

is a complex interaction that includes central tolerance in the thymus and bone marrow and peripheral tolerance involving T regulatory cells, peripheral anergy, and homeostasis produced by cytokines, chemokines, and their receptors. The thymus gland is principally responsible for eliminating or suppressing aggressive or intolerant self-reactive (autoreac- tive) lymphocytes (see Chapter 9). However, a small number of T cells escape thymic control and move into the peripheral circulation. The immune system has other peripheral “checkpoints” to detect, limit, and control these “self” or “auto” reactive T cells that have escaped the thymus gland. Peripheral tolerance involves T-cell intrinsic mechanisms that lead to clonal deletion, or anergy, as well as extrinsic control by T suppressor cells, primarily CD4+CD25+FOXp3+Tregs. T suppressor cells regulate potentially harmful autoreactive T and B cells. Autoimmune diseases result when self-tolerance is lost and reactions between self antigens and the immune system occur, causing dysregulation of proinflammatory and antiinflammatory mediators, cytokines, CD4+ and CD8+ T cells, B cells, and ubiquitin-editing enzyme A20 in dendritic cells.

Multiple theories have been proposed to explain how various immune system components and environmental triggers might interact to produce autoimmunity. However, no single theory can fully explain the loss of self-tolerance that occurs in autoimmune diseases. A number of genetic, cellular, and environmental factors interacting together contribute to the development of autoimmunity. The triggers for autoimmunity are not known exactly because autoimmune diseases are mediated by a variety of mechanisms, biochemical and cellular events, and responses to those events. Newer theories emphasize the relationship between pathogens and both the innate immune system and the adaptive immune system.

The theory of antigenic or molecular mimicry emphasizes the similarities between certain molecular segments of foreign antigens called epitopes and the person’s own cells. For example, all cells, whether self or foreign, are composed of proteins, carbohydrates, nucleic acids, and lipids. Certain viruses and bacteria evolve to look like “self” and use “molecular mimicry” to slip past the immune system defenses. Self cells with the same or similar molecular segments as these foreign epitopes can “fit” lymphocyte receptors. Therefore these self antigens or autoantigens can be attacked as foreign under certain circumstances when the normal cell has been altered, such as by a bacterial or viral infection that stimulates the immune response. The persistent presence of these autoantigens then acts as a constant source of stimulation to the immune system. This theory is suggested as a cause of rheumatic heart disease attributable to cross-reactions between Streptococcal antigenic protein M and human protein lysoganglioside leading to the development of cardiac-reactive T cells and autoimmunity. Another example is the interaction between Epstein–Barr virus (EBV) peptide with a “self” protein (PPPGMRPP peptide of Sm) that occurs in patients with SLE. In both cases, autoantigens have been identified following exposure to bacterial or viral infection.

Another theory proposes that activation and release of preexisting autoreactive immune cells (or sequestered antigens) trigger the auto- immune response. This theory of hidden/cryptic antigens suggests that certain self antigens are isolated from the immune system within an organ during the neonatal period. They are not in contact with antigen- processing cells during the embryonic period when self-tolerance usually occurs. These hidden self antigens or sequestered proteins, normally sheltered from immune recognition, occur in sites such as the cornea of the eye, the testicles, brain, or other areas not drained by lymphatics. If and when these sites are damaged later in life, the hidden or sequestered proteins are exposed to the immune system, which does not recognize them as self. Therefore the damaged cells are attacked. In this theory, bacterial or viral infections cause the tissue damage that leads to exposure

The purpose of the immune system is to defend the body against invasion or infection by foreign substances, called antigens, and to patrol for and destroy cells that are abnormal or damaged. Normally, the immune system works efficiently to accomplish these purposes, but in some situations inappropriate immune responses lead to disease.

These disorders can be divided into two general categories: (1) excessive immune responses, and (2) deficient immune responses. The category of excessive immune responses includes disorders in which the immune system is overfunctioning or hyperfunctioning, such as autoimmunity and hypersensitivity disorders. Autoimmune diseases are complex, multifactoral chronic diseases that occur in response to polygenetic as well as environmental factors. The estimated overall prevalence ranges from 3% to 10% of the general population.

The category of deficient immune responses includes disorders in which the immune system fails to respond to provide protection and is ineffective because of disease-causing genotypes or secondary/acquired dysfunction. Examples of deficient immune responses are severe combined immunodeficiency (SCID) syndrome, DiGeorge syndrome, and selective immunoglobulin A (IgA) deficiency. Human immunode- ficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is a primary acquired immunodeficiency disorder that is discussed in Chapter 12. The secondary immunodeficiencies associated with white blood cell malignancies are included and discussed in Chapter 11.

EXCESSIVE IMMUNE RESPONSES Excessive immune response disorders result from a functional increase in the activity of the immune system involving multiple interacting immune cells. Autoimmunity and hypersensitivity are types of excessive immune response disorders that are often related, and both may be present in patients. It may be helpful to think of autoimmunity as a way of describing the etiologic process, or cause, of abnormal excessive immune responses toward self tissues. Hypersensitivity disorders describe mechanisms of injury, or how the injury occurs, which may or may not involve autoimmunity. Autoimmunity is a general term that is used when the immune system attacks its own tissues. Most autoimmune reactions toward self tissues are mediated through type II (cytotoxic) and III (immune complex) hypersensitivity mechanisms. For this reason, many autoimmune diseases also are considered hypersensitivity reactions. For example, myasthenia gravis is both an autoimmune disease and a type II hypersensitivity reaction. Immune complex glomerulonephritis is both an autoimmune disease and a type III hypersensitivity reaction. When hypersensitivity reactions occur in response to foreign antigens, such as bee venom, they are not autoimmune.

The causes of immune system overreactions involve a complex interplay between genetic factors, including major histocompatibility complex (MHC) genes, and environmental factors thought to be important in the development of autoimmune disorders. Autoimmune disorders range from organ-specific diseases to organ-nonspecific diseases. Examples of organ-specific diseases include multiple sclerosis, where the target organ is the central nervous system, or in type 1 diabetes, where the target organ is pancreatic beta-islet cells. Examples of organ- nonspecific diseases include systemic lupus erythematosus (SLE) or Sjögren syndrome where multiple organs are involved.

AUTOIMMUNITY Autoimmunity occurs when the immune system recognizes a person’s own cells (“self”) as foreign and mounts an immune response that injures self tissues. It is a failure of self-tolerance. The adaptive immune response is the responsibility of antigen-specific T cells and B cells that learn to identify “self” in the thymus and bone marrow. Self-tolerance

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Mast cells release the cytokine interleukin-1 (IL-1), attracting and enlisting inflammation-inducing cells to joints and leaking fluid into joints in the autoimmune disease of rheumatoid arthritis. They are also thought to be involved in the development of irritable bowel syndrome and other functional gastrointestinal disorders.

Genetic Factors Genetic factors play a role in the development of autoimmune disorders. Gender, which is genetically determined, also influences the expression of autoimmune disorders. The exact mechanisms of gender and genetic influence on autoimmune expression have not been established, but the relationship is significant. Females are at significantly higher risk for developing autoimmunity compared with males. Different cytokine profiles can be associated with autoimmunity. Those with genetically low levels of tumor necrosis factor-α (TNF-α) and high levels of IL-10 may be more tolerant than those with normal levels.

The role of genetics is also supported by the observation that certain human MHC genes located on chromosome 6p21 (also called human leukocyte antigen [HLA] genes) encode molecules involved in antigen presentation and are critical in distinguishing self from nonself. The HLA genes are frequently associated with autoimmune disorders (Table 10.1). The MHC gene region demonstrates a high level of polymorphism. They are associated with the highest genetic risk in many autoimmune diseases.

One of the strongest correlations of MHC molecules with autoimmune disease is the linkage between the HLA-B27 phenotype and ankylosing spondylitis. In this case 95% of all people with ankylosing spondylitis have a positive B27 phenotype. However, not everyone with a positive B27 phenotype develops ankylosing spondylitis, both because of dif- ferences in the way antigen is presented to the immune system and because of environmental factors. Other diseases are associated with different MHC phenotypes, but the correlation between risk for disease and presence of the disease marker is much lower. For example, Addison disease is associated with the HLA-DR3 phenotype, but it has only a 6% risk correlation. Juvenile rheumatoid arthritis is strongly associated with HLA-DR5.

There may also be disease-causing genotypes or genetic factors affecting expression of immune factors. For example, the lymphoid protein tyrosine phosphatase nonreceptor type 22 (PTNP22) gene is found in patients with many autoimmune disorders, including type 1 diabetes, rheumatoid arthritis, SLE, Grave disease, and Crohn disease. TNF-α is involved in acute and chronic inflammation, autoimmunity, and malignancies. Of special interest is the FOXP3 gene, which is expressed by CD4+ regulatory T cells. FOXP3 deficiency is associated with both primary immune deficiency disorders and autoimmune disorders owing to its effect on regulatory T-cell immune function.

Environmental Triggers Chronic or multiple viral or bacterial infections may trigger the develop- ment of autoimmune disease in susceptible persons. For example, acute rheumatic fever occurs in people who are genetically susceptible to Streptococcus pyogenes through molecular mimicry. Viruses can activate B cells, decrease the function of T cells, contribute to the development of antigenic mimicry, or insert viral components on cell surfaces and trigger immune reactions. For example, viruses (EBV, cytomegalovirus [CMV]), bacteria (gram positive and negative such as Streptococcus, Campylobacter jejuni, and Helicobacter pylori), parasites (trypanosomes and Ascaridia galli), and fungi (Saccharomyces cerevisiae) have been cited as potential triggers of autoimmune disease.

A variety of noninfectious environmental factors have been associated with autoimmunity such as foods, pharmaceutical agents, smoke, ultraviolet light, vitamin D, hormones, vaccines, and heavy metals. A

of the “hidden” self antigens. However, this theory is now in question because it states that microbes and tissue damage are needed to cause autoimmunity. For example, people undergoing heart surgery and transplantation all produce autoantibodies to heart antigens, but they do not develop myocarditis, an autoimmune cardioinflammatory disease.

A similar theory is called the adjuvant or bystander effect. This theory states that an infection, which stimulates the immune system, activates receptors on immune cells causing the release of proinflammatory cytokines. These cytokines then activate preexisting autoreactive T and B cells that previously escaped thymic detection and deletion. It is unclear if this is a nonspecific (any immune cell) reaction or an innate immune-specific reaction, such as against a specific toll-like receptor.

A number of T -cell theories of autoimmunity have been proposed, including thymus gland defects, decreased suppressor T-cell function, and altered T helper cells. The epitope spread theory states that recurrent infection or damage to a particular organ causes the immune system to develop multiple autoantibodies. Theories attributing autoimmunity to thymus gland defects state that maturation and differentiation of T cells are affected either by decreased hormone secretion or by failure of the thymus to expose T cells to all self products. The thymus gland is responsible for exposing developing T cells to self products produced in the thymus or carried to the thymus gland. If some self products are not exposed to the developing T cells, the product will not be recognized as self and will subsequently be attacked. However, recent evidence demonstrates that not all T cells maturate in the thymus. Thus not all T cells may experience or “learn” to recognize “self.” This lack of exposure to self products is thought to be a major factor in the development of generalized autoimmune diseases.

The theory attributing autoimmunity to decreased or lost regulatory/ suppressor T-cell (Treg) activity states that decreased numbers of Treg cells fail to repress immunoglobulin activity. Some data suggest that Treg cells lose their forkhead box p3(FOXP3) protein and are transformed into effector T cells. It is also unclear if this disruption in the number of, or activity of, T cells may also be the result of genetic mutations. For example, a mutation of the transcription factor (FOXP3) causes impaired development and function of CD4+ T cells, which can lead to autoimmune inflammation. T helper cells 22 (Th22 cells) are a newly identified subset of T cells that are important mediators of chronic inflammation and autoimmunity by inducing the production of inflam- matory cytokines (ll17a, ll17f, ll22, ll26) by CCR6+ cells. Additionally, the development of autoimmunity may be secondary to an imbalance or alteration of autoreactive effector T cells and their ability to be controlled by Tregs. Decreases in peripheral Tregs (pTreg) and/or thymus Tregs (tTreg) can lead to autoimmunity, as both are needed to prevent it in certain inflammatory conditions. Current thinking suggests that both are needed to prevent autoimmunity in peripheral tissues of healthy people.

A number of B-cell theories of autoimmunity also have been proposed. The theory attributing autoimmunity to escape of B-cell tolerance proposes that certain B cells lose their responsiveness to suppressor T-cell messages. The B-cell activation theories, which are well supported clinically and experimentally, suggest that extrinsic factors or intrinsic genetic B-cell defects cause autoantibody production and an increase in the number and activity of B cells. A number of extrinsic factors, including viruses, bacteria, antibiotics, proteolytic enzymes, and lipo- polysaccharides, have been found to be B-cell–activating factors that could trigger autoantibody production.

Research has linked mast cells to autoimmunity as well as to hyper- sensitivity. Mast cells reside in most mucous membranes waiting for foreign proteins or bacteria to invade. Their cell membranes are studded with bacteria-sensing proteins, called toll-like receptors, which cause release of up to 10,000 different chemicals in response to activation.

CHAPTER 10 Alterations in Immune Function 197

Although the etiology of autoimmunity continues to be investigated, the mechanisms whereby autoantibodies injure tissues are better understood. The autoantibodies produced by autoimmune disorders affect tissue by the mechanisms described for type II and type III hypersensitivity reactions found later in this chapter.

Pharmacotherapies The ideal therapeutic approach to treat autoimmune disease would be a medication that inhibits abnormal immune responses without limiting the positive and protective functions of the immune system or causing any organ toxicity. Unfortunately, no medication with these specific properties yet exists.

Immunosuppressive therapy is a common treatment for autoimmune disease. Because autoimmunity is expressed in different ways, the immunosuppressive treatment for each type of autoimmune disease is individualized, depending on disease expression. Immunosuppressive

good example is the relationship between gluten ingestion and the development of celiac disease. Another example is the exposure to ultraviolet light that leads to oxidative damage to DNA and RNA, induces cell death, and promotes the release of cytokines TLR7 and TLR9. This can induce the development of SLE, rheumatoid arthritis, or multiple sclerosis in susceptible individuals.

Environmental stress and occupational stress can affect the immune system because of their relationship to neuroendocrine system hormones, leading to inflammation or lymphokine release that activates T cells. Neuroendocrine and immune system interaction during life stress, such as shift work or workplace stress, promotes the synthesis and overproduction of proinflammatory cytokines. In genetically susceptible persons, this increase in systemic and local proinflammatory cytokines may affect the system’s balance enough to trigger autoimmune disease. There are also other linkages between the neuroendocrine and immune systems.

TABLE 10.1 Autoimmune Diseases, Major Histocompatibility Genes, Auto-Antibodies, and Target Organ

Disease Age at Onset and Gender Ratio (F/M) HLA (MHC) Antigen Auto-Antibodies Target Organ

Multiple Sclerosis 20–40 2/1

HLA Class I: HLA-A*02:01 HLA Class II: DRB1 …

Antibodies against myelin protein Central nervous system (CNS)

Rheumatoid arthritis 44–55 2/1

HLA Class II: DR4 DR1 HLA Class III: TNF

Anti-CCP, RF-IgG, ACPA, anti-Carp Synovium of joints

Graves disease 50–60 5/1

HLA Class I: HLA-B8 HLA Class II: DR3 and DR4

Anti-TSHR auto-antibodies Thyroid

Type 1 diabetes mellitus

6–13 1/1

HLA Class I: HLA-A and B HLA Class II: DQ2 and DQ8

IAA, GADA, IA-2A, ZnT8A Pancreas β-islets

Systemic lupus erythematosus

30–50 9/1

HLA Class II: DR3 DR2 DR8 DR6 HLA Class III: TNF C2, C4, ……

Antinuclear antibody, antidsDNA antibody, anti-Sm, antiphospholipid antibody

Multiple organs: heart, joints, skin, lungs, blood vessels, liver, kidneys, CNS

Primary biliary cirrhosis

50–60 10/1

HLA class II: DRB1*08, DRBI*11,

DRBI*13 protective

AMA Small and medium-sized intrahepatic bile ducts

Sjögren syndrome 40–50 9/1

HLA Class II: DRB1 ……

Anti-Ro/SSA, anti-La/SSB, ANA Mainly salivary and lacrimal glands; other organs: lungs, liver, kidneys, CNS

Crohn disease 15–30 and 60–80 1/1.2

HLA Class II: DR7, DRB3, DR2, DR3

Anti-TG2, antigliadin Gastrointestinal tract

Addison disease 15–45 0.8–2.4/1

HLA Class II: DR3/DQ2 DR4.4/DQ8 DQB1

ACA Adrenal glands

Data from Wang L et al: Human autoimmune diseases: a comprehensive update, J Intern Med 278(4):369–395, October 2015.

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plasma or a plasma cell type as well as protein-bound toxic substances. The patient’s whole blood is filtered, blood cells and platelets are returned, and the plasma component containing the autoantibodies is removed and replaced with 5% albumin or another colloid solution. According to the American Society for Apheresis, this type of therapy has been effective in the management of diseases such as myasthenia gravis, thrombocytopenia purpura, multiple sclerosis, and Rh-negative hemolytic disease of the newborn. Plasmapheresis is generally well tolerated; however, there are both major and minor risks involved in the process. Some of the risks include insertion of large intravenous (IV) catheters to perform the procedure, decrease in serum ionized calcium concentra- tion, shifts of fluid levels, and risks of infection and bleeding from loss of coagulation factors.

therapy has become an increasingly important treatment choice. These medications are essential for inhibiting excessive or aberrant immune responses, but must be taken continuously to achieve the goal of inhibit- ing the immune system response to self antigens.

Immunosuppressive agents include corticosteroids, TNF inhibi- tors, immunomodulators, and cytotoxins. Corticosteroids (cortisone, prednisone, or budesonide) decrease the number of lymphocytes and decrease antibody formation, as well as alter the functional activities of lymphocytes. They also have many other activities as a result of their glucocorticoid function. Corticosteroids tend to be used in the treatment of many autoimmune diseases and are the oldest of the immunosup- pressive drugs. The adverse effects that occur during corticosteroid use often limit their extended use over time. The common side effects include hypercorticism with changes in fat distribution and buffalo hump formation, suppression of the hypothalamic–pituitary–adrenal (HPA) axis, congestive heart failure, hypertension, emotional changes, thinning of skin, petechiae, diabetes mellitus, menstrual irregularities, electrolyte imbalances, liver and pancreatic dysfunction, exophthalmos, glaucoma, osteoporosis, loss of muscle mass, and muscle weakness. Because corticosteroids affect the HPA system, gradual withdrawal by tapering the dose over time is necessary when discontinuing long-term therapy.

Cytotoxins, such as methotrexate, are used to manage autoimmune disorders because of their ability to inhibit folic acid metabolism and kill actively proliferating lymphocytes after they are transformed from their resting G0 state. They also selectively down-regulate B-cell function. The key to the use of cytotoxins is to effectively apply their killing activity without damaging the rest of the body. Cyclosporine (Sandim- mune) is a more selective immunosuppressant that reversibly suppresses T helper cells in the G0 or G1 phase of the cell cycle without killing them. As a result, it inhibits the development of killer or cytotoxic T cells without decreasing the numbers of cells. It also impairs the ability of T cells to respond effectively to foreign antigens. It is used to suppress reactions during tissue or organ transplantation. Frequent side effects include predisposition to infection, pulmonary fibrosis, edema, hyperten- sion, headache, hirsutism, elevated triglyceride levels, gastrointestinal effects, nephropathy, emotional changes, skin pigmentation, gynecomastia, leukopenia, anemia, and hepatotoxicity.

TNF inhibitors or immunomodulators, such as etanercept (Enbrel), adalimumab (Humira), golimumab (Simponi), or infliximab (Remicade), are used as disease modifiers that bind to and block the activity of TNF-α and TNF-β. They may also modulate TNF-mediated responses, such as leukocyte migration and expression of adhesion molecules. The most common side effects of TNF inhibitors include predisposition to infections, headache, gastrointestinal changes, injection-site skin reactions or infusion reactions, respiratory tract infections, edema, dizziness, dyspepsia, weakness, malignancies, and neurologic disorders.

Purine analogs such as azathioprine inhibit the synthesis of DNA and are used in multiple autoimmune diseases. Side effects include increased risk of malignancy, bone marrow suppression, nausea, and vomiting. There are also new medications, such as tocilizumab, an IL-6 inhibitor; abatacept, a CTLA4-immunoglobulin; alemtuzumab, an anti-CD52 medication; and rituximab, an anti-CD20 antibody, that target specific immune system components or cells. Other new therapies are being developed that target Treg defects in order to restore their function. These new medications are expected to be safer than older, nonspecific therapies. Novel approaches are also being developed such as transplantation of pancreatic B cells for type 1 diabetes along with thymus tissue to ensure graft tolerance without long-term immunosuppression.

Therapeutic plasmapheresis is another type of therapy occasionally used in the management of autoimmune diseases. Plasmapheresis is analogous to dialysis and involves the selective filtering or removal of

KEY POINTS • Autoimmune disorders occur when the immune system erroneously reacts

with “self” tissues. These disorders are thought to be polygenic and mul- tifactorial; however, the exact etiologic process is unknown.

• The antigenic mimicry theory involves the alteration of viruses or bacteria to look like “self” and the precipitation of immune reactions.

• The theory involving release of sequestered antigens suggests that self antigens that do not come in direct contact with lymphocytes during fetal development may cause autoimmune reactions if they are subsequently released from sequestration.

• Abnormal production of subclasses of T lymphocytes, particularly suppressor T cells, has been proposed as a reason for the development of autoimmunity, as well as the development of abnormal B cells that do not respond to suppressor T-cell signals.

• Genetic factors such as female gender and major histocompatibility complex (MHC) genes are associated with certain autoimmune disorders.

• Autoantibodies injure body tissues through the mechanisms described for type II and type III hypersensitivity reactions.

HYPERSENSITIVITY Hypersensitivity is a normal immune response that is inappropriately triggered, excessive, or produces undesirable effects on the body. The basic mechanism that triggers hypersensitivity is a specific antigen– antibody reaction or a specific antigen–lymphocyte interaction. Four classes or types of hypersensitivity are differentiated: types I, II, III, and IV. Each type is characterized by a specific cellular or antibody response. Types I, II and III are mediated by antibodies. Hypersensitivity type I is an immediate or IgE-mediated reaction, such as anaphylaxis. Hypersensitivity type IIa is cytotoxic or IgG/IgM mediated, and type IIb is antibody-mediated cell stimulating. Hypersensitivity type III reaction is IgG/IgM immune complex mediated such as immune complex glomerulonephritis and SLE. Type IV hypersensitivity is T cell mediated and has four major categories. Type IVa is mediated by CD4+ Th1 cells with activation of macrophages. Type IVb is CD4+ Th2 lymphocyte mediated with eosinophilic involvement, such as persistent asthma. Type IVc is mediated by cytotoxic CD8+ T lymphocytes with involvement of perforin-granzyme B in apoptosis, as seen in Stevens– Johnson syndrome (SJS). Type IVd is T-lymphocyte–driven neutrophilic inflammation.

Hypersensitivity reactions are specific to a particular antigen and usually do not occur on first exposure to the antigen. Although the diseases or syndromes associated with each type differ in their clinical signs and symptoms, the underlying pathophysiologic process is similar within each type. The four major types of hypersensitivity are contrasted in Table 10.2. The complex interactions between immune system inflammatory mediators, cytokines, T cells, B cells, and mast cells

CHAPTER 10 Alterations in Immune Function 199

(allergen) entry into the body. This increased entry would subsequently increase IgE responsiveness.

Mast cells and basophils are the principal effector cells, although many other cells with histamine and other inflammatory mediators can be involved in the reaction. These may include neutrophils, eosino- phils, lymphocytes, macrophages, epithelial cells, and endothelial cells. Mast cells are found throughout the body in all loose connective tissue. They are covered with IgE receptors—up to 500,000 on their cell surfaces—and they are filled with vesicles or granules containing potent vasoactive, proinflammatory chemical mediators (especially histamine) that produce inflammation when they are released. The IgE receptors on mast cells bind the Fc portion of an IgE antibody. The IgE antigen- binding sites are then displayed on the mast cell surface, where they can bind to antigens that pass by the mast cell (Fig. 10.1). This process makes the mast cells responsive to particular antigens.

The initial incident during a type I hypersensitivity response is the cross-linking of two IgE receptors to one antigen on the mast cell located at the site of the allergen’s entry into the body (see Fig. 10.1). Cross- linking of IgE and the antigen causes an increase in intracellular calcium (Ca2+) concentration that results in immediate, massive, local mast cell degranulation of preformed and newly formed proinflammatory media- tors. The release of mediators causes an inflammatory response.

Mast cells, basophils, and other effector cells release many chemicals that act to trigger evolving immune responses, promote continuing sensitivity, and promote the transition of allergic disease into chronic illness. Some of the mediators are preformed and stored in vesicles, such as histamine, heparin, proteolytic enzymes, cytokines, and

characterize hypersensitivity reactions. Some diseases have multiple types of immunologic hypersensitivity.

Type I Hypersensitivity Etiology Genetic mechanisms influence type I hypersensitivity with strong genetic or hereditary linkage regarding the IgE response to antigens (allergens). This genetic component involves both the ability to respond to an allergen and the general ability to produce an IgE antibody response. Genome-wide association studies have identified hundreds of genetic variants and have contributed to a greater understanding of type I hypersensitivity/allergic diseases. However, the specific causal genetic mechanisms are still unclear. A positive family history remains a strong predictor of allergic disease.

Pathogenesis Type I hypersensitivity is also known as immediate hypersensitivity, because the reaction is immediate. It is a sensitization reaction character- ized by signs and symptoms of an allergic reaction that usually occurs 15 to 30 minutes after exposure to an antigen (allergen).

At the cellular level, immunoglobulin E (IgE) is the principal antibody mediating this reaction. IgE is produced by specialized plasma B cells and circulates in very small amounts in the blood. When an individual is exposed to an allergen, selected plasma B cells produce allergen-specific IgE. It usually takes repeated exposures to the allergen to cause significant levels of IgE to be present in the blood. Environmental pollutants may play a role by increasing mucosal permeability and enhancing antigen

TABLE 10.2 The Four Types of Hypersensitivity

Characteristic Type I: Atopic, Anaphylactic

Type II: Cytotoxic, Cytolytic

Type III: Immune Complex (Arthus Reaction)

Type IV: Delayed Hypersensitivity

Mediated by: IgE IgM or IgG IgG and complement CD4+ Th1 or Th2 cells, CD8+ cells

Complement activation No Yes Yes No Immune response Ag plus IgE, leading to mast

cell degranulation Surface Ag and Ab, leading

to killer cell cytotoxic action or complement- mediated lysis

Ag–Ab complex deposited in tissues; complement activated and PMNs attracted

Ag-sensitized T cells release cytokines, leading to inflammatory reaction and recruitment of macrophages, eosinophils, or neutrophils, which release cytokines

Peak action 15–30 minutes 15–30 minutes or can occur over time

6 hours or more 24–48 hours or more

Serum transferability Yes Yes Yes No Cell transferability No No No Yes (T cells) Genetic mechanisms Familial

High IgE level HLA-linked Ir genes General hyperresponsiveness

HLA linked in some cases Familial (autoimmune) HLA specificities

Unknown

Causes of reaction T-cell deficiency Abnormal mediator feedback Environmental factors and

Ag exposure

Exposure to Ag or foreign tissue, cells, or graft

Persistent infection— microbe Ag

Extrinsic environmental Ag Autoimmunity—self Ag

Intradermal Ag Epidermal Ag Dermal Ag

Manifestation (examples)

Bee sting reaction, allergic reactions, rhinitis

ABO transfusions, hemolytic disease of newborn, myasthenia gravis

Graves disease

Immune-complex glomerulonephritis, SLE, farmer’s lung arthritis, vasculitis

Allergic contact dermatitis, Stevens–Johnson syndrome, toxic epidermal necrolysis, pustular psoriasis

Ab, Antibody; Ag, antigen; DTH, delayed-type hypersensitivity; Ig, immunoglobulin; HLA, human leukocyte antigen; PMN, polymorphonuclear leukocyte; SLE, systemic lupus erythematosus.

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which are located on many types of cells. Mast cells have receptors for H1, H2, and H3, with H1 receptors being the most active. Basophils express predominantly H2 receptors, whereas neutrophils and eosinophils have both H1 and H2 receptors. Recent evidence shows that H1 and H2 receptors are present on monocytes and macrophages, with an increase in H1 receptors when monocytes differentiate into macrophages. Histamine binding to H1 receptors triggers increased vascular perme- ability, vasodilation (flushing), urticaria formation (hives), smooth muscle constriction (bronchoconstriction), increased mucus secretion and pruritus (increased itching), and increased gut permeability. The activation of H2 receptors has opposing effects to H1 receptors in some tissues and causes smooth muscle relaxation in the lower airways, augments gastric acid secretion from parietal cells, and in high concentra- tions has an inhibitory effect on inflammatory cells, decreasing both degranulation and neutrophil chemotaxis. The H3 receptors are located in the brain, in the spinal cord, and on sensory neurons such as post- ganglionic cholinergic nerves in lung bronchi. The H4 receptors are found on immune system cells such as dendritic cells, eosinophils, T cells, monocytes, macrophages, and natural killer cells, as well as in hematopoietic cells such as the spleen, thymus, bone marrow, and blood leukocytes. H4 receptors are highly attracted to histamine and are also involved in chemotaxis and inflammatory responses.

The proteolytic enzymes kininogenase and tryptase activate the kinin pathway, and C3 activates the complement cascade via the alternative pathway. Heparin decreases clot formation. The chemotactic factors recruit or activate other inflammatory and immune cells. Leukotrienes cause smooth muscle contraction and increase vascular permeability. Increased intestinal expression of IL-9 by mucosal mast cells is found in patients with food-mediated hypersensitivity.

Clinical Manifestations Manifestations of an immediate hypersensitivity reaction vary in severity and intensity. For many people, type I hypersensitivity reactions are annoying, such as hives (urticaria), seasonal allergic rhinitis, eczema, or mild bronchoconstriction. In other people, the symptoms are more problematic, including tightening of the throat, localized edema, wheez- ing, and tachycardia, such as is associated with localized angioedema reactions or severe airway reactions. In a very small number of highly allergic people, the type I hypersensitivity reaction can be expressed as a life-threatening allergic reaction known as anaphylaxis. Anaphylaxis is often caused by bee stings, seafood, or peanut ingestion. Common allergens that can trigger type I hypersensitivity reactions are listed in Box 10.1.

Treatment Treatment for type I hypersensitivity primarily involves pharmacologic management with antihistamines, β-adrenergics, corticosteroids, anticholinergics, and anti–immunoglobulin E therapy (IgE blocker therapy). Antihistamines such as diphenhydramine (Benadryl) are used to block the effect of histamine. This action decreases vascular perme- ability and bronchoconstriction. β-Adrenergic sympathomimetics are used to decrease bronchoconstriction and bronchospasm. Epinephrine is an adrenergic agent (α, β1, and β2) given subcutaneously or intrave- nously during acute allergic reactions, especially after medication, food, or bee sting reactions. Most patients with severe allergies to food or insect bites are given prescriptions for epinephrine in the form of EpiPen with an autoinjector. Corticosteroids are used to decrease the inflam- matory response. Anticholinergics are used to block the parasympathetic system and thus allow greater sympathetic activity. This action indirectly causes bronchodilation. Anti–immunoglobulin E therapy (omalizumab) may be used for persons with severe persistent asthma. Omalizumab (Xolair) is a subcutaneously injected, monoclonal anti-IgE antibody

chemotactic factors. Other mediators are formed during the degranulation process. Examples of newly formed mediators include superoxide, prostaglandins, thromboxanes, leukotrienes, bradykinin, and interleukins (see Chapter 9).

One of the most important mediators of type I hypersensitivity is histamine. Histamine binds to H1 (histamine 1), H2, H3, and H4 receptors,

1 First exposure to antigen

Helper T cell

B cell

2 Production of IgE antibodies

3 Binding of IgE to Fc receptors on mast cells

4 Exposure of mast cell to antigen with cross-linking of IgE- Fc receptors

5 Release of mediators (degranulation)

6 Signs and symptoms of inflammation

Fc receptor

Ca++

Ca++

Ca++

FIG 10.1 Type I hypersensitivity reaction.

CHAPTER 10 Alterations in Immune Function 201

children from families with a history of allergies. These actions include avoiding foods to which the mother is allergic, limiting excesses of one type of food during the last trimester of pregnancy, avoiding whole eggs during the last month before delivery and while breast feeding, and limiting cow’s milk to two glasses per day. Other actions that may be helpful during the child’s infancy include avoiding exposure to environmental pollution, breast feeding for a minimum of 6 months, supplementing the child’s diet with non–cow’s milk products such as soy milk, giving solid foods only after the infant is 6 months old, keeping the infant’s room as free of dust and molds as possible, and keeping pets (dogs, cats, birds) out of the home.

Pharmacotherapeutic Prevention Another avenue for prevention of type I hypersensitivity reactions involves the use of desensitization therapy (immunotherapy). Desensitiza- tion is more successful in patients with hay fever than in those with other types of allergies. It involves both environmental control of external allergens and titrated pharmacologic exposure to allergens. Pharmacologic immunotherapy is particularly effective when exposure to the allergen can’t be avoided (i.e., pollens, molds, insect venoms, and dust mites). Environmental control involves a systematic plan to decrease exposure to house dust, molds, and animal dander. Pets are kept out of the house. The person must avoid food allergens, wool carpets, goose down or feather pillows, dried plants, and exposure to other animal and vegetable products. The person is urged to use air conditioning and electronic air filters.

Pharmacologic immunotherapy or desensitization involves giving a person an antigen (allergen) in gradually increasing dosages weekly or biweekly over a course of months or years in order to induce tolerance. The antigen (allergen) can be given sublingually or by subcutaneous injection. After the initial series, periodic maintenance or booster therapy is used to maintain tolerance. Gradually, the dose is increased until the person can tolerate the allergen without a type I hypersensitivity reaction. The goal of this therapy is a change in immunoglobulins so that there is an increase in IgG- and IgA-blocking antibodies, no increase in IgE during allergy season, decreased basophil reactivity, and decreased lymphocyte reactivity to allergens.

Type IIa Hypersensitivity Etiology and Pathogenesis Type IIa hypersensitivity, also known as tissue-specific, or cytotoxic, or IgG/IgM-mediated hypersensitivity, is characterized by antibodies that attack antigens on the surface of specific cells or tissues. Often the reaction is immediate (15 to 30 minutes after exposure to the antigen). However, it can occur over time, such as in myasthenia gravis. The mechanisms that encompass type II tissue-specific hypersensitivity all occur after the binding of antibody to tissue-specific antigens. The reaction is mediated by the complement system and a variety of effector cells, including tissue macrophages, platelets, natural killer cells, neu- trophils, and eosinophils. IgG and IgM are the principal antibodies. Examples of this type of hypersensitivity reaction include ABO transfu- sion reactions, hemolytic disease of the newborn, myasthenia gravis, hyperacute graft rejection, and autoimmune hemolytic anemia. Transfu- sion reactions, hemolytic disease of the newborn, and graft rejection are examples of isoimmunity (alloimmunity), a condition in which the immune system reacts against antigens on tissues from other members of the same species.

The initial mechanism during a type II hypersensitivity response is exposure to antigens on the surface of foreign cells. The Fab portion of IgG or IgM antibodies binds to antigens on the target foreign cell to form an antigen–antibody complex (Fig. 10.2). (Refer also to Chapter 9 for a discussion of IgG and IgM antibodies.) The Fc region of the

that binds to the IgE molecule, thus inhibiting the binding of IgE to mast cells and basophils and promoting down-regulation of IgE receptors. It is used to improve asthma control in patients with moderate-to-severe persistent asthma not controlled with inhaled corticosteroids. It is used in children 12 years or older and in adults.

Prevention Some protective, proactive actions taken during pregnancy are thought to decrease the likelihood that type I hypersensitivity will develop in

Medications Penicillin, penicillin analogs, and other antibiotics Radiographic contrast media Aspirin, indomethacin, and other nonsteroidal antiinflammatory drugs (NSAIDs) Anesthetic agents

Biological Agents Allergenic extracts and antisera Serum proteins, including γ-globulin and monoclonal antibodies Insulin and other hormones Vaccines Enzymes such as penicillinase Blood products Latex Pollen from grass, trees, flowers, and weeds Mold spores Pet dander Dust mites Cockroach saliva, feces, or shedding body parts

Insect Venom Hymenoptera (stinging) insects Polistes wasps Honeybees Fire ants Hornets and yellow jackets

Foods Peanuts Tree nuts Seafood, especially shellfish Eggs Fruit, especially citrus and strawberries Milk Tartrazine, yellow dye no. 5 Wheat Soy Sesame seeds, mustard seeds, or other seeds

Inorganic Chemicals Nickel Aluminum Zinc

Irritants Cigarette smoke Perfumes Diesel exhaust High levels of air pollution

BOX 10.1 Possible Causes of Human Allergic Reactions or Anaphylaxis

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Binding by macrophage followed by cell phagocytosis

Fc receptor

Antigen- antibody complex with Fc

bridging

Cell lysis

Complement activation followed by

cell lysis via membrane attack complex (MAC)

Fab portion of antibody (IgG or IgM)

Fc region of antibody (IgG or IgM)

Antigen-antibody complex

C1

MAC

Blood transfusion with type B blood

Person with type A blood and anti-B antibodies (IgG or IgM)

Macrophage

Phagocytosis

B

B

A

A

A

B

B

B

B

A

FIG 10.2 Type II hypersensitivity reactions.

IgG or IgM antibodies protrudes away from the cell membrane surface. The Fc region then acts as a bridge between the antigen and complement or the effector cells. This antigen–antibody binding with Fc bridging is the key and leads to lysis of the cell by one of several mechanisms. One mechanism is complement-mediated lysis. Complement-mediated lysis occurs through the classical pathway for activation of complement. The classical pathway of complement generates the activated complement component C3b via splitting of C4 and C2 by C1 (see Chapter 9). The activated complement component C3b is bound to the target cell by the Fc region of IgG or IgM. C3b increases opsonization, which in turn increases the capacity of the system to allow lysis by other effector cells or by complement itself. Lysis of the foreign cell by complement occurs via the C5–C9 membrane attack complex (MAC), which disrupts the plasma membrane of the cell.

Transfusion Reaction An example of this type of mechanism is an acute hemolytic blood transfusion reaction that occurs when a person receives blood from someone with a different blood group type (Table 10.3). In this case the recipient of the blood transfusion has antibodies to the donor’s red blood cell (RBC) antigens. For example, if a person with type A blood with type A antigens and anti-B antibodies incorrectly receives type B blood with B antigens and anti-A antibodies, the anti-B antibodies will attach to the surface of the infused type B RBCs (see Fig. 10.2) and the anti-A antibodies in the infusion will attach to the surface of the circulat- ing type A RBCs. This event will stimulate the destruction of large numbers of RBCs. The resulting signs and symptoms of this major blood group reaction include fever, chills, flushing, tachycardia, hypoten- sion, low back pain, pleuritic chest pain, nausea, vomiting, restlessness,

CHAPTER 10 Alterations in Immune Function 203

with or without complement involvement. An example of this type of mechanism is hemolytic disease of the newborn (erythroblastosis fetalis).

This condition occurs during pregnancy when an Rh-negative mother is sensitized to the Rh-positive red cell group antigens of her fetus because of exposure during her current or a previous pregnancy. The mother’s IgG Rh-positive antibodies cross the placental barrier and attack the red blood cells of the fetus. The mother’s exposure occurs when mixing of fetal and maternal blood takes place. This can occur during an episode of antepartal bleeding or trauma to the placenta, during birth, or during miscarriage of an Rh-positive child. Of these situations, the most likely time for mixing of fetal and maternal blood is at the time of delivery. After this exposure, Rh-positive antibodies gradually develop in the mother and can affect her subsequent children. It takes as little as 1 cm3 of fetal blood exposure for antibodies to Rh- positive RBCs to develop in the mother. Usually, the first Rh-positive child is not affected unless placental tearing or leakage into the mother’s circulation occurs during pregnancy.

Antibody screens are routinely performed during pregnancy to determine a mother’s Rh status, including indirect Coombs test and identification of specific antibodies. If the mother is Rh-negative, RhoGAM is administered at 28 weeks, after any prenatal bleeding, and at delivery for prevention of Rh-positive antibodies. RhoGAM contains antibodies against Rh antigens on fetal blood cells and is given to the mother to destroy fetal cells that may be present in her circulation before her immune system becomes activated and begins to produce anti-Rh antibodies. RhoGAM is not effective if the mother already has

anxiety, oliguria, and headache. The reaction may progress to shock and death.

Transfusion reactions are not always immediate. They may be delayed from a few days to 2 weeks, especially in persons requiring periodic transfusions such as in sickle cell anemia or thalassemia. In many cases, antibodies occur as a result of blood component exposure from multiple transfusions. Delayed reactions can also occur as a result of transplanta- tion. In delayed transfusion reactions, often the mechanism of action is related to differences in erythrocyte (RBC) antigens between blood donors rather than differences in the major ABO blood groups. Many hundreds of RBC antigens have been identified; fortunately, most of them are rare. In patients with sickle cell anemia, delayed hemolytic transfusion reactions can occur due to differences in RBC antigens between blood donors with resulting alloimmunization. The rate of alloimmunization with the development of delayed transfusion reaction in sickle cell patients is higher than in other patient populations. The resulting type II hypersensitivity reaction causes the destruction of both the donor’s and the recipient’s RBCs along with the symptoms of acute hemolysis, and severe vasoocclusive crisis.

Hemolytic Disease of the Newborn A second mechanism for antigen–antibody binding in type II hyper- sensitivity reactions is direct destruction by Fc-bearing effector cells, such as macrophages. The macrophage can link to exposed Fc antibody regions. Once this bridging occurs, the foreign cell is phagocytized and destroyed by lysosomes within the effector cell. This can be mediated

TABLE 10.3 Major Blood Groups Blood Group: Phenotype Antigens Possible Genotype Antibodies in Serum Chromosome

A A AA or AO Anti-B 9q34.2 B B BB or BO Anti-A AB A and B AB None O H OO Anti-A, Anti-B

Other Clinically Significant Major Blood Group Systems: Phenotype Number of Antigens Most Common Major Antigens Clinically Significant Antibodies

Rhesus (Rh): 50 D, C, E, c, e Rh+ DD; Dd Rh− dd Anti-D; Anti-c; Anti-C; Anti-E; Anti-e Kell or Kell – Cellano:

25 K, k Anti-K; Anti-Ku; Anti-k; Anti-Kpa

Anti-Kpb; Anti-Jsa; Anti-Jsb

MNS: 46 M, N, S, s, U Anti-S; Anti-s; Anti-U; Anti-M; Anti-N Duffy: 6 Fya; Fyb; Fy3; Fy4; Fy5, Fy6 Anti-Fy3; Anti-Fya; Anti-Fyb

Kidd: 3 Jk1 (Jka); Jk2 (Jkb) and Jk3 Anti-Jka; Anti-Jkb

Derived from: Dean L. Blood Groups and Red Cell Antigens [Internet]. Bethesda, MD – National Center for Biotechnology Information (US), 2005.

Frequency of Blood Types in the U.S. Population: Blood Type Caucasian African American Hispanic Asian

O+ 37% 47% 53% 39% O− 8% 4% 4% 1% A+ 33% 24% 29% 27% A− 7% 2% 2% 0.5% B+ 9% 18% 9% 25% B− 2% 1% 1% 0.4% AB+ 3% 4% 2% 7% AB− 1% 0.3% 0.2% 0.1%

Source: American Red Cross Blood Types Chart.

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symptoms of myasthenia gravis include ptosis, diplopia, and muscle weakness after exercise that improves with rest.

Hyperacute Graft Rejection Another type II hypersensitivity mechanism for antigen–antibody binding that involves both effector cells and complement is the hyperacute graft rejection that affects transplanted tissues. It occurs when the transplanted donor tissue has an antigen to which the recipient has preformed antibodies. For example, when tissue from a blood type A or B donor is transplanted into a blood type O recipient, the recipient has anti-A and anti-B antibodies. These antibodies will immediately attack the foreign transplanted tissue.

Onset begins immediately after revascularization of the transplanted tissue. At this time, the blood supply from the patient is established in the newly transplanted organ. The patient’s antibodies attack the foreign protein antigens and form an antigen–antibody complex. Effector cell infiltration and complement-mediated lysis of donor tissues, inflam- mation, vascular thrombosis, and hemorrhage occur. The reaction happens so quickly that within 48 hours after transplantation the graft tissue is no longer functioning.

To prevent hyperacute graft rejection, tissue and blood typing of donors and recipients of transplanted tissue is extensive. Lists of potential recipients are matched to donors through organ donation laboratories both regionally and nationally. Only rarely has hyperacute graft rejection occurred because of an error in tissue or blood typing.

Type IIb Hypersensitivity Graves Disease Graves disease is an example of a type IIb hypersensitivity reaction that occurs as a result of an immune attack on the thyroid gland. The mechanism for antigen–antibody binding in this type IIb hypersensitiv- ity reaction is mediated by lymphocytes, which infiltrate the thyroid parenchyma. The underlying mechanism(s) that triggers this process is still being investigated, but infection, diet, iodine, stress, and smoking may be contributing factors. In Graves disease, circulating IgG autoantibodies (called anti-TSHR antibodies) attack the thyroid-stimulating hormone receptor. This causes the cells to malfunction, stimulating the receptor and producing excess thyroxine (T4) and triiodothyronine (T3). The major symptoms of hyperthyroidism include tachycardia, fatigue, weight loss, tremor, heat intolerance, diarrhea, and emotional/mental changes.

Type III Hypersensitivity Etiology Type III hypersensitivity results from failure of the immune and phagocytic systems to effectively remove antigen–antibody immune complexes and is not tissue specific. It is also known as an immune complex reaction. Type III hypersensitivity is characterized by antigen– antibody complex deposition into tissues, with consequent activation of complement and a subsequent self-sustaining inflammatory reaction. It is not an immediate reaction; it occurs over a period of several hours or longer (i.e., glomerulonephritis) and is often ongoing.

Three possible scenarios can precipitate type III hypersensitivity. First, a recent history of infection or persistent low-grade infection by a microbial or viral agent can stimulate a weak antibody response. The continuing nature of persistent infection or untreated/undertreated infection provides a source of circulating antigen. The antigen and antibody response leads to chronic immune complex production. These immune complexes are not successfully removed from the blood and are deposited in many sites, including blood vessels, glomeruli, and joints. Second, an extrinsic environmental antigen from molds, plants, or animals can be inhaled into the lung, where it is exposed to antibody in the body fluid. This inhalation of an antigen causes antigen–antibody

a positive antibody titer for fetal Rh antigens. The routine administration of RhoGAM to women at risk is clinically effective with rare findings of hemolytic disease of the newborn.

If the mother is Rh negative, already has fetal Rh antibodies (i.e., is sensitized), and is carrying an Rh-positive fetus, she will not exhibit any significant physiologic effects except some discomfort from potential polyhydramnios. The mother may experience psychological distress. Most of the symptoms of Rh sensitization occur in the fetus, including signs of anemia, hypoxia, decreased fetal activity, ascites, congestive heart failure, and an elevated baseline heart rate of 180 beats/minute or greater with late decelerations. As a result, there is frequent fetal surveillance by 26 weeks’ gestation, including assessment of fetal heart rate, biweekly performance of nonstress tests, execution of serial amniocenteses to measure levels of bilirubin, and/or direct evaluation of fetal hemoglobin and hematocrit levels by means of percutaneous umbilical blood sampling. If fetal anemia becomes severe any time after 18 weeks’ gestation, an intrauterine blood transfusion may be necessary to try to prolong the time the fetus is able to stay in utero. After 34 weeks, the fetus is often taken by cesarean section.

Myasthenia Gravis Myasthenia gravis is an autoimmune disease of the neuromuscular junction. Antibodies are directed primarily against the nicotinic ace- tylcholine receptor (AChR) on the postsynaptic membrane at the neuromuscular junction. However, antibodies against other proteins can occur, including muscle-specific kinase, or low-density lipoprotein receptor–related protein 4 on muscle membrane surfaces, especially the motor end-plate, or agrin in the postsynaptic membrane at the neuromuscular junction (Fig. 10.3). With antigen–antibody formation at the receptor site, complement is activated and disrupts the muscle cell membrane. B cells are the principal mediator cells. The thymus gland is believed to be the site of anti–AChR antibody development. It also sustains the autoimmune, hypersensitivity reaction. The loss of acetylcholine stimulation at the motor end-plate causes the extreme muscular weakness associated with myasthenia gravis. The major

Neuron

Axon terminal

Antibodies to acetylcholine receptors

Acetylcholine receptor

Acetylcholine vesicles

Acetylcholine

Motor end-plate postsynaptic folds

FIG 10.3 Type II hypersensitivity reaction in a person with myasthenia gravis. Having limited receptors available for acetylcholine impairs neuromuscular transmission.

CHAPTER 10 Alterations in Immune Function 205

and is deposited into tissues. When only the antibody is soluble, the antibody reacts with fixed antigen in the tissues. Then the antibody within the complex links with the complement system by its Fc receptors (Fig. 10.4).

Activation of the classic complement cascade causes release of C3a and C5a, as well as the membrane attack complex. C3a stimulates the release of histamine from mast cells, indirectly increasing vascular permeability and vasodilation. Bronchial smooth muscle contraction occurs, resulting in bronchial constriction, wheezing, and coughing. C3a also causes the endothelial cells to become rounder, thereby increasing vascular permeability. The increased vascular permeability leads to edema formation, which provides more space for the movement of cellular inflammatory components. It also dilutes and limits the duration of action of mediators. C5a is an even more powerful component than C3a.

complex formation in alveoli with immune complex deposition in the alveolar walls. Third, an autoimmune process can develop in which autoantibodies attack self antigens. In this case the body forms both parts of the immune complex. Autoantibodies to either circulating or tissue-fixed self antigens may be produced. Because the self antigens persist over time, chronic immune complex production and deposition in tissues take place.

The mechanism of injury in type III hypersensitivity reactions is from activation of complement and other proinflammatory mediators in response to the antigen–antibody complex deposition. The antibody– antigen complex deposition does not cause the injury directly. The tissue injury is caused by an inflammatory reaction to the antibody– antigen complex. Therefore it is not a tissue-specific reaction. The onset of this reaction occurs up to 6 or more hours after exposure to the antigen. IgG and IgM are the principal antibodies. The principal effector cells are neutrophils and mast cells. The principal mediator of the reaction is complement. Examples of type III hypersensitivity reaction include SLE, immune complex glomerulonephritis, serum sickness, and drug- induced vasculitis. Diseases associated with type III hypersensitivity are listed in Table 10.4.

Pathogenesis Type III hypersensitivity reactions tend to be ongoing with variations in symptoms based on the fluctuation of antibody-to-antigen ratios, the amount of complement available to mediate the inflammation, and the dynamic nature of the antibody–antigen reaction. It is sometimes difficult to differentiate between type II and type III hypersensitivity reactions. The key differences between a type II and a type III reaction are the location of antigens and the mechanism of injury. As previously described, type II reactions occur in response to tissue-specific antigen located on cell surfaces and involve direct cell death or malfunction from the antigen–antibody reaction. Type III hypersensitivity reactions involve antigens forming antigen–antibody complexes that precipitate out of the blood or body fluid and are deposited into tissues.

Type III hypersensitivity reactions involve a sequential process that begins with interaction between a circulating soluble antigen and soluble antibody or between an insoluble antigen and a soluble antibody. Depending on the concentration of antigen and antibody, multiple cross-linking of antigen and antibody occurs and immune complexes are formed. Most immune complexes are removed effectively before they can cause injury. In type III hypersensitivity, the immune complexes are not removed, which causes an inflammatory process leading to tissue injury.

When both antigen and antibody are small or intermediate in size and soluble, the immune complex precipitates out of the body fluid

TABLE 10.4 Diseases Associated With Type III Hypersensitivity

Disease Antigen

Immune complex glomerulonephritis

GBM, exogenous antigens, drugs

SLE Double-stranded DNA, DNA-histone complex, Sm, RNP, Ro:SSA, La:SSB, centromere

SLE-associated glomerulonephritis

Double-stranded DNA, DNA-histone complex, Sm, RNP, Ro:SSA, La:SSB

Acute allergic alveolitis Various puffball spores from moldy dwellings Farmer’s lung disease Thermophilic Actinomycetes from

contaminated hay or grains Chemical worker’s lung Isocyanates Still disease—

postinfectious arthritis RANA, or none identified

Rheumatoid arthritis RANA Serum sickness Lymphocytes or thymocytes from

heterologous serum Henoch–Schönlein purpura Upper respiratory tract viruses, drugs

(antibiotics and thiazides), foods (milk, fish, eggs, rice, nuts, beans), and immunizations

Drug-induced vasculitis Drugs (antibiotics and thiazides) Polyarteritis nodosa Antineutrophil cytoplasmic Wegener granulomatosus Antineutrophil cytoplasmic Goodpasture syndrome GBM

GBM, Glomerular basement membrane; La, Lane; RANA, rheumatoid arthritis nuclear antigen; RNP, ribonucleoprotein; Ro, Robert; SLE, systemic lupus erythematosus; Sm, Smith; SS, single stranded.

Deposits in tissue

Antigen-antibody complex formed

in blood Activation of complement

and chemoattraction of neutrophils

Release of enzymes and free radicals

Fc receptor

Tissue destructionBasement membrane

FIG 10.4 Type III hypersensitivity reaction.

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hematuria, hypertension, oliguria, and red cell casts in the urine (see Chapter 27). In some types of glomerulonephritis, the patient may have nephrotic syndrome and acute renal failure that may progress to chronic renal failure.

Treatment of glomerulonephritis involves the use of corticosteroids and other medications to decrease inflammation. Antihistamines and antiserotonins have been tried in attempts to decrease vasoactive media- tors and vascular permeability. Anticoagulants and antiplatelet medica- tions such as aspirin, as well as plasmapheresis, are currently being studied. In plasmapheresis, plasma is removed from the blood and fresh frozen plasma or albumin is used to replace the withdrawn plasma.

Systemic Lupus Erythematosus Etiology. SLE is an example of a type III hypersensitivity reaction

caused by autoantibody production. SLE tends to occur more frequently in women than in men (ratio of 7 : 1) and with an incidence of 20 cases per 100,000 persons. It is primarily characterized by the development of antibodies against nuclear antigens such as DNA, deoxyribonucleohistone, and RNA. Production of autoantibodies to RBCs, neutrophils, platelets, lymphocytes, and other organs or tissues may also occur. The antinuclear antibodies (ANAs) and anti-DNA autoantibodies attach to components of the nucleus to form immune complexes that are deposited on collagen- rich tissues, including the glomerular basement membrane and the dermal-epidermal junction. The exact mechanism causing cell damage and the release of nuclear components and subsequent development of ANA and anti-DNA antibodies is not known. It is proposed that the release of nuclear material from the cell occurs during cell death or secondary to pyroptosis, a proinflammatory process that leads to the release of intact nuclei. Once formed, the autoantibodies can react with DNA and nuclear components from damaged cells anywhere in the body. The resulting inflammatory response causes increased cell damage and further antigen–antibody immune complex formation, thus leading to a cyclic process. The immune complex deposition and resulting inflammatory response cause the signs and symptoms of SLE.

Clinical manifestations. SLE can affect any organ system and, as such, it can present with a variety of signs and symptoms. Because of the variable presentation, diagnostic-specific criteria based on the presence of specific signs, symptoms, and laboratory findings have been developed. Kidney involvement is common and may lead to nephritis and glomerulonephritis. Skin symptoms are wide ranging and include malar “butterfly” rash, erythematous rash on exposed skin, purpura, alopecia, mucosal ulcerations, subcutaneous nodules, and splinter hemorrhages. The malar butterfly rash occurs across the nose onto the cheeks in approximately 26% of patients with acute SLE. The butterfly rash can be flat or raised and always spares the nasolabial folds. The rash that occurs on sun-exposed skin can be superficial or indurated and is nonpruritic. It can occur on the face, chest, shoulders, extensor surfaces of the arms, and backs of the hands. The color ranges from red to reddish purple. Most patients have symptoms of arthritis or polyarthralgia. Other symptoms include pleurisy, pericarditis, restrictive pulmonary disease, retinal changes, thrombocytopenia, anemia, and gastrointestinal ulceration. Central nervous system involvement includes neuritis, seizures, depression, or psychosis. A positive ANA test is usually present with positive anti-DNA (antibody to native DNA) and anti-Sm (antibody to Smith nuclear antigen) (see Chapter 52 for more information).

Treatment. Treatment of SLE depends on the organ system affected and includes administration of nonsteroidal antiinflammatory drugs (NSAIDs) such as aspirin, systemic corticosteroids, antimalarials such as hydroxychloroquine (Plaquenil), alkylating agents such as cyclophos- phamide, and immunosuppressives such as methotrexate, abatacept or belimumab (Benlysta). NSAIDS are used for arthritis symptoms, general- ized aching, and fever. Antimalarials are a common treatment for SLE

It causes a powerful release of proinflammatory mediators with actions that are identical with those of C3a. It is also a powerful chemotactic agent for neutrophils and causes a respiratory burst within neutrophils in which oxygen consumption is increased to 50 times normal along with increased glucose uptake and procoagulant activity.

As a result of the activation of complement, neutrophils, macrophages, and mast cells are attracted to the area and are activated. These cells begin lysis and destruction of tissue via the release of cytokines and the inflammatory response. The inflammation causes tissue destruction, scarring, and further reaction of the immune system against the damaged tissue (see Fig. 10.4). The persistence of the inflammation is due to the ongoing release of autoantigen particles in the damaged tissue that stimulate autoreactive B cells, leading to the formation and deposition of more immune complexes.

Tissue Deposition Antigen–antibody complex deposition in tissues is affected by a number of factors, including size and clearance rate. Smaller immune complexes are able to circulate for longer periods, which may increase the immune response. However, small complexes also can be removed more easily because they can pass through the glomerular basement membrane. The very large complexes can be phagocytized more easily because they are easily marked or fixed by complement and bound to red blood cells. The large complexes can then be transported to the liver, where they are phagocytized by the reticuloendothelial system—particularly the Kupffer cells in the liver—and easily removed from the system. However, large complexes can become stuck in the kidney where they are unable to cross the glomerular basement membrane.

Increased vascular permeability as a result of histamine or other vasoactive mediator release is also hypothesized to be an important factor in tissue deposition. Researchers have found that small immune complexes can be deposited in tissues treated with vasoactive mediators. Sites of increased turbulence and blood pressure tend to have increased immune complex deposition. These sites include the glomerular capil- laries, joint linings, ciliary body, pulmonary alveolar membranes, and vascular endothelial linings, especially around curves or bifurcations.

Intermediate-sized immune complexes tend to be deposited because they do not fix complement well, do not bind with RBCs well after fixa- tion, and are not readily removed by the mononuclear phagocyte system. Large numbers of any size immune complex can be deposited if they are so numerous that the phagocytic cells are overwhelmed. Deposition of immune complexes also depends on their immunoglobulin class and the affinity between the antigen and antibody. Finally, deposition may be affected by the type of antigen or by the relationship between the immune complex and sites with increased collagen. Because DNA and collagen have a strong affinity, an increased quantity of DNA–anti-DNA immune complexes may be deposited in collagen membranes, such as in the kidney. The electrical charge of the immune complex may affect where it is deposited. For example, a positively charged immune complex may be attracted by a negatively charged basement membrane.

Immune Complex Glomerulonephritis Etiology. Immune complex glomerulonephritis (an inflammatory

renal disorder) is an example of a type III hypersensitivity reaction typically occurring 10 to 14 days after infection with a Streptococcus or staphylococcal bacterial strain. It involves the interaction of soluble bacterial antigens with soluble antibodies and is a frequent cause of glomerulonephritis. The circulating immune complex is then deposited in the glomerular capillary wall and mesangium.

Clinical manifestations and treatment. This deposition causes glomerular inflammation, activation of mesangial cells, and ultimately damage to the glomerular basement membrane with resultant proteinuria,

CHAPTER 10 Alterations in Immune Function 207

because of failure of lysosome–phagosome fusion, as in tuberculosis and leprosy, or because of the resistance of various materials to internal lysozymes, as in retained suture material or talc. In an effort to protect the host, lymphocytes and macrophages actually cause the tissue damage by releasing cytokines and stimulating an inflammatory response.

Antigen is engulfed and ingested by macrophages attempting to destroy the antigen, but these actions are unsuccessful in type IV hypersensitivity. The macrophages form a core of inflammatory cells that include lymphocytes, tissue histiocytes, eosinophils, plasma cells, giant cells, and epithelioid cells. This collection of inflammatory cells develops into a ball-like mass called a granuloma. The predominant cell in the granuloma is the macrophage. Epithelioid cells originate from macrophages and are large, flat cells with a large amount of endoplasmic reticulum. When epithelioid cells fuse, they form multinucleated giant cells. This core is surrounded by lymphocytes. Gradually, fibroblastic activity and increased collagen synthesis cause the granuloma to become fibrotic with scar formation. Often, central necrosis occurs within the granuloma and is called caseous or cheesy necrosis. Patients with granulomatous disease have a variety of symptoms. Granulomatous disease examples and the pathogens associated with them are listed in Table 10.5.

Testing for granulomatous diseases also involves skin testing. For example, the tuberculin skin test (i.e., Mantoux or purified protein derivative [PPD]) identifies infection but is not diagnostic of active disease. The test involves intradermal injection of 0.1 mL of PPD into the volar surface of the forearm. There should be a clear bleb at the site of the test. The skin test is then read in 48 to 72 hours. A negative PPD skin test is one in which there is either no reaction or only redness at the site. A positive result is one in which there is equal to or greater than 10 to 15 mm of induration (or tissue firmness) at the site. In patients with HIV a positive result is equal to or greater than 5 mm of induration. However, if the HIV patient’s CD4+ cell count is low (<200 cells/µL), or if the patient is febrile or elderly, there may be no reaction to any skin testing. This is called anergy and causes a false negative in many cases.

Type IVa – Tuberculin-Type Hypersensitivity Tuberculin-type hypersensitivity is a type of allergic contact dermatitis and occurs when someone who has been previously infected by tuber- culosis is exposed to tuberculin antigen in a tuberculin test. It is a dermal phenomenon that peaks in 48 to 72 hours. The person experiences erythema, induration, and inflammation at the site of the intradermal injection. Because the amount injected is so small, the reaction disappears when the antigen has degraded. However, people with severe reactions may experience tissue necrosis at the site.

Type IVa – Allergic Contact Dermatitis Allergic contact dermatitis is the most familiar kind of type IV hyper- sensitivity. It is an immune or inflammatory response to a wide variety

because of their effectiveness in treating arthritis and rash symptoms. The major side effect of antimalarials is ocular toxicity, which can be prevented by limiting therapy to 10 years or less, not exceeding 6.5 mg/ kg/day dosages, and undergoing yearly ophthalmic evaluations. Other side effects include myopathy, pigmentation changes, gastrointestinal effects, liver enzyme changes, dizziness, and emotional changes.

Corticosteroids decrease inflammation and provide immunosup- pression, which can decrease symptoms and add to the patient’s quality of life. Corticosteroids are used for kidney and central nervous system involvement in SLE. If the patient does not respond to corticosteroids, immunosuppressives or cytotoxic agents can be used. Methotrexate is a commonly used immunosuppressive (see earlier). Benlysta is a monoclonal antibody that inhibits B cells and is used only when there is severe, aggressive disease. It is given intravenously every 4 weeks and is very expensive. It is associated with risks for infection, malignancy, and depression. Antibiotics are commonly prescribed because of frequent infections secondary to immune system compromise. Sunscreens with maximum sun protection factor values are necessary to prevent pho- tosensitivity reactions. Patients are also encouraged to avoid direct sunlight from 10 am until at least 3 pm.

Type IV Hypersensitivity Type IV hypersensitivity, also known as a delayed hypersensitivity reaction, is characterized by tissue damage resulting from a delayed cellular reaction to an antigen. This hypersensitivity category has been reclassified into four subclasses that are divided by the type of principal mediator and cytokines involved. The principal mediators are lymphocytes, including CD4+ T helper (Th1) cells, Th2 cells or antigen-sensitized cytotoxic CD8+ T cells (Tc), macrophages, mast cells (in the early phases), and neutrophils. They mediate the reaction by releasing a cascade of cytokines. This reaction is slow in onset and evolves gradually—beginning 24 hours after exposure and lasting up to 2 to 4 weeks after exposure. Clinical manifestations may linger for an even longer period.

Mast cell degranulation occurs early in the evolution of a delayed hypersensitivity reaction, followed by lymphocyte and macrophage invasion. The mast cells are gatekeepers that regulate leukocyte migration in the microvasculature. Unlike that occurring in type I hypersensitivity reactions, the mast cell degranulation is more limited and localized. The reaction is also limited by the action of suppressor T cells, which inhibit other T-cell actions. The reasons for mast cell activation in this type of hypersensitivity reaction are not well understood. However, the combined action of mast cell and T-cell mediators recruits other T cells and macrophages to the site.

The four subclasses of type IV hypersensitivity are IVa) mediated by CD4+ Th1 cells and macrophages/monocytes with cytokines interferon (IFN) gamma, IL-1, IL-2, IL-3, and IL-31; IVb) mediated by CD4+ Th2 cells and eosinophils with cytokines IL-5, IL-4, and IL-13; IVc) mediated by cytotoxic CD8+ T cells with perforin, granzyme B, and Fas ligand; and IVd) mediated by CD4+ T cells, CD8+ T cells, and neutrophils with cytokines IL-6, IL-8, IL-17A, IL-17F, IL23, IL-36, and granulocyte- macrophage colony-stimulating factor.

Many types of delayed hypersensitivity reactions are recognized, including granulomatous hypersensitivity, persistent asthma, allergic contact dermatitis, tuberculin-type hypersensitivity, SJS, toxic epidermal necrolysis (TEN), and pustular psoriasis (PP).

Type IVa — Granulomatous Hypersensitivity Granulomatous hypersensitivity reaction is a primary defense against intracellular infections and represents a chronic type IV hypersensitivity reaction. It is a protective defense reaction that eventually causes tissue destruction because of persistence of the antigen. In this type of hypersensitivity, antigen is not destroyed within the macrophages, either

TABLE 10.5 Granulomatous Disease Associated With Type IV Hypersensitivity

Disease Bacterium

Tuberculosis Mycobacterium tuberculosis Leprosy Mycobacterium leprae Histoplasmosis Histoplasma capsulatum Coccidioidomycosis Coccidioides immitis Brucellosis Brucella abortus

Brucella suis (less common) Brucella melitensis (less common)

Tularemia Francisella (Pasteurella) tularensis

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dendritic cells or Langerhans cells are the antigen-presenting immune cells of the skin and mucous membranes. These cells then move to the local lymph channel, where they migrate to the regional lymph node. Within the lymph node, the dermal dendritic cells display the now- processed complete antigen to CD4+ T cells in the paracortex. Then the antigen-sensitized CD4+ T cells release a cytokine cascade of vasoactive substances, which initiate an inflammatory response and attract other effector cells. The primary cytokines include IL-2, IL-3, IL-31, IFN, TNF, and macrophage-stimulating factors (Fig. 10.5). After about 72 hours, the reaction begins to decrease because of degradation of the antigen and production of prostaglandin E, which inhibits IL-1 and IL-2 production.

As a result of the antigen exposure, T cells bearing receptors for the specific antigen are formed and enter the bloodstream. Any future exposure or contact with the antigen can trigger a cellular reaction, which takes place at each subsequent exposure site. This is called the

of plant oils, chemicals, ointments, clothing, cosmetics, dyes, and adhesives. It is an epidermal phenomenon with two phases: an induction or sensitization phase and an elicitation phase. As a delayed reaction, it peaks in 48 to 72 hours and is usually resolved within 4 weeks, provided that continued exposure to the antigen is avoided.

During the induction phase, a skin-penetrating antigen is applied to or touches the epidermis or a mucosal membrane. The antigen is very small, low in molecular weight, and in an incomplete form. This incomplete, lipid-soluble antigen is called a hapten. The hapten must first penetrate the epidermal barrier (stratum corneum), where it links with a normal body protein, called a carrier. Only after the hapten combines with the carrier is it a complete antigen—often called a hapten conjugate. The means of contact or the antigenic compound itself may help in the sensitization of the epidermis during the induction phase.

The complete antigen is then processed by Langerhans cells or other dermal dendritic cells located in the suprabasal epidermis. The dermal

Hapten Epidermis

Protein (carrier)

1 Exposure to hapten with formation of complete antigen (hapten conjugate)

2 Recognition and processing of antigen by antigen- processing cell (APC)

3 Migration of APC to lymph node where antigens are presented to T cells

4 Release of cytokines that stimulate proliferation of T cells and activate macrophages

Helper T cell

Cytokines

APC

APC

5 Activated T cells and macrophages migrate to the epidermis, release inflammatory mediators, and cause cell destruction

Macrophage T cells

FIG 10.5 Type IV hypersensitivity reaction.

CHAPTER 10 Alterations in Immune Function 209

p53, as well as the release of retinoic acid. The result of this activation causes extensive keratinocyte apoptosis, leading to the symptoms of severe blistering, skin peeling, and multiorgan damage, particularly in the liver. A similar cascade of immune system–activated products occurs when a type IVc hypersensitivity occurs to respiratory infectious agents.

The medications most commonly implicated in SJS/TEN include anticonvulsants (phenytoin, phenobarbital), antibiotics (sulfonamides, aminopenicillins, antifungals), antimalarials, allopurinol, and certain NSAIDs. The treatment of SJS/TEN includes fluid replacement, nutri- tional support, and extensive wound care, as well as the use of medications such as antihistamines, corticosteroids, or immunoglobulin therapy and plasmapheresis.

Type IVd – Pustular Psoriasis PP is a type IVd hypersensitivity reaction. It is a rare and severe form of psoriasis distinguished by the presence of neutrophilic collections intradermally. In type IVd hypersensitivity, CD4+ T cells or CD8+ T cells activate neutrophils as well as a cascade of proinflammatory cytokines, including IL-6, IL-22, IL-23, IL-17A, and IL-17F. The skin lesions are a complex interaction between dendritic cells, keratinocytes, and T cells. Symptoms of PP include repeated attacks of diffuse, erythematous, pustular rash associated with high-grade fever, general malaise, and leukocytosis. The rash is often located in flexural areas. Treatment includes use of topical or systemic corticosteroids and phototherapy, as well as medications including acitretin, cyclosporine, methotrexate, and TNF-blocking medications such as infliximab (Remicade).

elicitation phase. Langerhans cells with the antigen interact with specific T cells, resulting in cytokine activation and release, as well as the prolifera- tion of other inflammatory mediators and CD4+ T cells.

Cross-reactivity with the related substances also occurs. For example, a person with allergic contact dermatitis to nickel will react when exposed to a variety of nickel alloys, including the metal in earrings, zippers, snaps, and belt buckles. Skin symptoms resulting from contact dermatitis include redness (erythema), edema, pruritus, and blisters. People with sensitivities may also experience respiratory symptoms if exposed to aerosolized hapten. This situation could occur when a person is downwind from burning poison ivy or burning tires. Delayed hypersensitivity reaction (type IV) caused by exposure to the compounds in latex gloves is an occupational risk in surgeons and nurses who work in operating rooms.

Patch testing for diagnosis of allergic contact dermatitis is indicated when symptoms persist despite avoidance of the suspected agent and with appropriate use of topical therapy. There are several types of patch tests, including open and closed testing used by dermatologists and allergists. In open patch testing, the suspected allergen is applied twice daily to the upper arm and left uncovered for 2 days. In closed patch tests, the suspected allergen is applied to the skin away from the original site of eruption and is covered with an adhesive bandage. The bandage is then removed in 2 days. The results are graded according to response. A 1+ positive patch test response involves erythema of the entire area of exposure. Patchy pustular responses are not positive and are irritant reactions. A 2+ patch test response involves erythema and vesicles. A 3+ patch test response involves erythema, vesicles, and bullae.

Type IVb – Persistent Asthma Persistent asthma is a form of type IVb hypersensitivity mediated by CD4+ T helper 2 (Th2) cells in response to a variety of stimuli. The CD4+ Th2 cells, as well as other T cells such as Th17, Th 22, and Th9, produce and release inflammatory cytokines and initiate eosinophilic involvement. This production of inflammatory cytokines includes IL-4, IL-5, IL-9, and IL-13, among others, as well as increased levels of IgE and eosinophil production. The interaction of these inflammatory vasoactive substances leads to the development of severe airway inflam- mation and asthma symptoms. The variability of individual asthma symptoms is influenced by multiple genetic, racial, and environmental factors that also influence the reactivity of the individual’s immune system. (See Chapter 22 for further discussion of asthma.)

Type IVc – Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis SJS and TEN are type IVc hypersensitivity reactions in response to medications or upper respiratory tract infection caused by herpes simplex virus or Mycoplasma pneumnoniae. Medications or their metabolites can interact with HLA class I alleles such as HLA-B*57:01 causing CD8+ T-cell activation with the production of cytokines. This type of immune system–mediated reaction is an adverse drug reaction that usually occurs approximately 4 to 14 days after starting a new medication, but may not occur for up to 6 weeks. In these cases, the immune-mediated reaction is a delayed reaction to a medication, in contrast to type I hypersensitivity reactions, which have an onset within 1 hour. In other patients, upper respiratory tract infectious agents interact with CD8+ T cells causing activation and release of cytokines. Because it is a delayed reaction, symptoms may not occur for 3 to 4 days and may last for 6 weeks.

When the onset of SJS/TEN occurs after ingestion of a medication, the medication or its metabolic byproduct binds directly to immune receptors on cytotoxic CD8+ T cells. Activation of the CD8+ T cells causes the release of secretory granulysin, perforin, and tumor suppressor protein

KEY POINTS • Type I hypersensitivity is an immediate allergic or anaphylactic type of

reaction mediated primarily by sensitized mast cells. The reaction is initiated when IgE antibodies located on the mast cell membrane are bound by antigen, with subsequent cross-linking of IgE receptors. Mast cell degranula- tion releases chemicals that mediate the signs and symptoms of anaphylaxis. Released histamine, kinin, prostaglandins, interleukins, and leukotrienes cause increased vascular permeability, vasodilation, hypotension, urticaria, and bronchoconstriction. Examples of type I reactions include acute drug reactions, bee sting reactions, and allergic contact dermatitis.

• Type II hypersensitivity occurs when antibodies are formed against antigens on cell surfaces, usually resulting in lysis of target cells. Cell lysis may be mediated by activated complement fragments (MAC) or by phagocytic cells that are attracted to target cells by the attached antibodies. Examples include transfusion reactions, erythroblastosis fetalis, myasthenia gravis, and hyperacute graft rejection.

• Type III hypersensitivity reactions occur when antigen–antibody complexes are deposited in tissues and result in the activation of complement and subsequent tissue inflammation and destruction. The antigen–antibody complexes activate the complement cascade and subsequently attract phagocytic cells to the tissue. History of persistent low-grade infections, inhalation of antigens into alveoli, and autoimmune production of antibodies may result in chronic production of antigen–antibody complexes. Examples include immune glomerulonephritis and systemic lupus erythematosus (SLE).

• Type IV hypersensitivity reactions are T-cell mediated and do not require antibody production, in contrast to type I, II, and III reactions. Sensitized T cells react with altered or foreign cells and initiate inflammation. Granulo- matous hypersensitivity, tuberculin reactions, persistent asthma, Stevens- Johnson syndrome (SJS), and pustular psoriasis (PP) are examples.

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such as HIV/AIDS. HIV/AIDS is described in Chapter 12, and only the congenital forms of primary immunodeficiency are included here. Primary congenital immunodeficiency disorders are genetic disorders that are often sex linked and occur in 1 in 58,000 infants. The most common primary disorders are listed in Table 10.6. There are also strong genetic epidemiologic data suggesting that many people have some inborn errors of immunity that may vary in clinical significance, expres- sion, and severity. This novel observation is changing how we view immunodeficiency. The first clinical indicators of immunodeficiency disorders are the signs and symptoms of infection.

B-Cell and T-Cell Combined Disorders Severe Combined Immunodeficiency Disorders

Etiology and pathogenesis. SCIDs are inherited PIDs that arise from a variety of genetic defects. There is wide phenotypic and immunologic variability in SCIDs with differences in their severity and clinical features. Nearly all SCIDs are characterized by the absence or dysfunction of T cells, which affects both cellular and humoral adaptive immunity. However, different forms of SCID may also have B-cell and natural killer (NK)–cell absence or dysfunction. For example, depending on the genetic defect, B cells may be present (T−B+) or absent (T−B−). Although B cells may be present, the B cells are unable to produce functional antibodies because of the absence of T-cell help.

T−B+ NK− X-linked SCID is thought to be the most common type of SCID. It is caused by mutations in the IL2RG gene that is responsible for encoding the common γ chain, which is needed by multiple cytokine

DEFICIENT IMMUNE RESPONSES Deficient immune responses result from a functional decrease in one or more components of the immune system. These disorders can affect lymphocytes, antibodies, phagocytes, and complement proteins. Two types of immune deficiency are differentiated: primary and secondary. Primary disorders are immune deficiencies not attributable to other causes; these may be congenital or acquired. Examples of primary immunodeficiency disorders include SCID syndrome, DiGeorge syn- drome, selective IgA deficiency, and HIV/AIDS. Persons with a primary immunodeficiency can be predisposed to multiple deficiencies, as in agammaglobulinemia or SCID, or can have a single phenotype deficiency predisposing to a specific problem, such as in patients with STAT-1 dependent chronic mucocutaneous candidiasis. Secondary immuno- deficiency disorders are a consequence of non–immune system disorders or treatments that secondarily affect immune function. Examples of secondary disorders include those associated with hyperlipidemia or malnutrition, medical treatments such as cancer chemotherapy, or biopsychosocial stress such as postsurgical immune suppression.

PRIMARY IMMUNODEFICIENCY DISORDERS Primary immunodeficiency disorders (PIDs) include congenital phe- notypes that result from abnormal development or maturation of immune cells, as well as acquired primary disorders of immune cells

TABLE 10.6 Primary Congenital Immunodeficiency Disorders

Disorder Functional Deficiency Error

X-linked agammaglobulinemia B cells; antibody btk gene mutation on long arm of X chromosome (Xq21.3-Xq22)

Common variable (acquired) hypogammaglobulinemia

Antibody; B cells may be decreased Unknown: possible CARMA1 variant and BOB1 variant

Selective IgA deficiency IgA antibody Unknown: possible alterations in transmembrane activator, calcium modulator, and cycophilin ligand interactor gene

Chronic mucocutaneous candidiasis B cells; secretory IgA antibody Autosomal-recessive deficiency in IL-17RA; autosomal- dominant deficiency of IL-17F

X-linked hyper-IgM syndrome Low levels of IgG and IgA; normal to elevated IgM antibody

Defect in CD40 ligand on T cells

Selective deficiency of IgG subclasses IgG antibody subclass Unknown Transient hypogammaglobulinemia of infancy Low IgG and IgA antibodies Unknown X-linked lymphoproliferative disease or Duncan

X-linked lymphoproliferative disease Anti–Epstein–Barr virus–linked antigen antibody Mutations in SH2D1A and XIAP (BIRC4)

22a11.2 deletion syndrome Primarily T cells Chromosome 22q11.2 deletion T−B+ NK− SCID — Autosomal recessive T cells, antibody Defects of JAK3 X-Linked recessive, T−B+ NK− SCID T cells, antibody Defects of IL2RG gene T−B−NK+ SCID (Omenn syndrome) T cells, B cells, antibody Mutations of RAG1 or RAG2 MHC class II expression deficiency (bare

lymphocyte syndrome) Lack of antigen Class II gene expression, T cells, antibody

Mutations in genes coding: class II transactivator (CIITA), RFX5 (regulatory factor X5), RFXAP (RFX-associated protein), or RFXANK

Wiskott–Aldrich syndrome (immunodeficiency with eczema and thrombocytopenia)

Antibody, T cells, platelets Mutation of WASp gene; defect of short arm of X chromosome at Xp11.23

Chédiak–Higashi syndrome Natural killer cells, phagocytic cells, granulocytes, platelets

Autosomal-recessive disorder; mutations in LYST (aka CHS1) gene on chromosome 1

Chronic granulomatous disease of childhood Phagocytic cells (neutrophils) Defect in superoxide generation; Mutations in genes CYBA, NCF-1, NCF-2, CYBB; most are X-linked recessive

btk, Bruton tyrosine kinase; JAK, Janus kinase; MHC, major histocompatibility complex; SCID, severe combined immunodeficiency; WASp, WAS protein.

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involved in cytoplasmic signaling, immune cell function, and regulation of the actin cytoskeleton in hematopoietic cells. The WASp deficiency upsets B-cell homeostasis with a decrease in mature peripheral B-cell subsets, which causes a dysfunction in B cells and abnormal serum immunoglobulins. Usually there is decreased IgM level, elevated IgE and IgA levels, and normal-to-low IgG level. This antibody variability is the result of increased antibody catabolism. Other laboratory findings include low-to-absent isohemagglutinins and low platelet count secondary to increased platelet destruction by the spleen due to abnormalities in platelet size and shape. Defects in peripheral self-tolerance are due to dysfunctions in regulatory and effector T cells. Affected infants have particular difficulty mounting immune responses to polysaccharide- encapsulated bacterial antigens.

Clinical manifestations and treatment. Wiskott–Aldrich syndrome is clinically characterized by the presence of microthrombocytopenia, eczema, and increased susceptibility to developing infection and malignancies. Affected children can develop bleeding manifested as bloody diarrhea, or cerebral hemorrhage and infections due to polysaccharide-encapsulated bacteria (S. pneumoniae and H. influenza) including pneumonia, meningitis, otitis media, and sepsis. They can also develop systemic autoimmunity, which increases the severity of their disease. The average age of these infants at death is 3.5 years without treatment.

Infants with Wiskott–Aldrich syndrome are treated with antibody replacement therapy and antibiotic therapy. Splenectomy, bone marrow transplantation, stem cell transplantation, and gene therapy are options used to manage this disorder in affected children.

T-Cell Disorders 22q11.2 Deletion Syndrome (DiGeorge Syndrome)

Etiology and pathogenesis. 22q11.2 deletion syndrome, also known as DiGeorge syndrome, is an autosomal-dominant developmental T-cell disorder due to a hypoplastic or aplastic thymus gland. The development of this syndrome is caused by a chromosomal 22q11.2 deletion (del 22q11) that results in defective fetal development. The abnormal chromosome is usually inherited from the mother. It is the most common microdeletion syndrome with an estimated prevalence of 1 in 4000 live births. Male and female children are equally affected by this condition. The immunodeficiency seen in this syndrome is due to total or partial loss of thymus gland function where T-cell maturation occurs. As a result, T cells are deficient to varying degrees. B cells are usually normal in number and function. Often the immune system impairment is minimal with normal-to-decreased numbers of T cells. In those patients with severe impairment due to absent T cells secondary to an aplastic thymus gland, B-cell function is abnormal as well. These patients have severe immunodeficiency that resembles SCID. There may also be associated genetic modifiers that vary in clinical presentation.

Clinical manifestations and treatment. Because 22q11.2 deletion syndrome is a congenital disorder of fetal organ development, it is often associated with other congenital problems, such as cardiac and great vessel anomalies, hypoparathyroidism with hypocalcemia, hypothyroid- ism, esophageal atresia or reflux, urogenital anomalies, growth restriction, developmental delay, psychiatric or behavioral problems, microcephaly, and dysmorphic facial features, including mandibular hypoplasia, short forehead, and protuberant or low-set ears. If the individual has minimal loss of thymus function, recurrent infections may not be a significant problem. However, recurrent infections occur in many to most patients. This increases the risk of fetal loss or infant death. For these children, thymic transplantation or bone marrow transplantation has been helpful in reestablishing T-cell populations. Specific treatments and therapies are needed for the management of these patients, particularly those with cardiac defects and hypocalcemia with seizures.

receptors, including IL-2, IL-4, IL-7, IL-9, IL-15, and IL-21. This defect results in the loss of all T-cell and NK-cell development. B cells are present but do not function normally. Another type of T−B+ NK− SCID is caused by a mutation in the gene encoding janus kinase 3 (JAK3 deficiency), which is important for differentiation of lymphoid cells. The result of this defect also causes low T cells and NK cells with nonfunctional B cells. The IL-7Ra gene–deficiency SCID is noted for low T cells but normal numbers of nonfunctional B cells and normal NK cells (T−B+ NK+ SCID).

T−B−NK+ SCID patients have a defect caused by mutations of recombination activating genes 1 or 2 (RAG1 or RAG2), both of which are involved in the process of antigen receptor gene assembly. This absence leads to abnormalities in T-cell and B-cell receptor expression and development. NK cell development is not affected because they do not express immunoglobulin-like receptors. Omenn syndrome is an example of this type of defect characterized by SCID, eczema-like rash, hepatosplenomegaly, and alopecia.

Adenosine deaminase deficiency SCID (ADA SCID) patients have a genetic mutation on chromosome 20q12.2-13.11. This T−B−NK− ADA SCID results in a deficiency of ADA, an intracellular enzyme of purine metabolism, whose function is to remove toxic metabolites formed in lymphocytes. As a result of this deficiency, there is an accumulation of toxic metabolites (particularly deoxyadenosine (dAdo) and deoxy- adenosine triphosphate (dATP)) which are lethal to T cells, B cells, and NK cells, as well as their precursors. Patients with this autosomal-recessive form of SCID have a complete absence of lymphocytes. They have severe recurrent infections and skeletal abnormalities.

Clinical manifestations and treatment. Untreated infants with SCIDs are severely ill with high early mortality — usually at less than 1 year. They are usually ill within 3 months of age and present with failure to thrive, persistent oral thrush, persistent diarrhea, severe Candida diaper dermatitis, recurrent severe infections, lymphadenopathy, and hepato- splenomegaly. Depending on the form of SCID, the infant may or may not have lymphopenia. They are prone to sepsis and opportunistic infections because they are unable to fight infections even if their B cells are present. They are susceptible to multiple pathogens such as Candida albicans or Pneumocystis jiroveci, viruses such as CMV or herpes virus, and common childhood diseases such as varicella and measles. Because of their severity, early recognition of infants with SCIDs is important and has led to the development of SCID screening of newborns. Persons with a positive family history can be tested antenatally if the genetic mutation is known, or screening can occur at birth. Newborn screening for SCIDs is currently conducted population-wide in 23 states, the District of Columbia, and the Navajo Nation.

Infants suspected of having SCID should be placed in protective isolation, and all staff involved in the infants’ care should be vigilant about following proper handwashing procedures and avoiding exposure to infections. The practice of avoiding other children is recommended when they are able to be discharged home. Breast feeding is encouraged if the mother is CMV negative and without active infection. Nasogastric or parenteral nutrition may be needed for adequate nutrition. Curative therapy involves hematopoietic stem cell transplantation with either umbilical cord blood or bone marrow preferably from HLA-haploidentical siblings. Other therapies include chemotherapy conditioning regimens, long-term immunoglobulin replacement therapy every 2 to 3 weeks, enzyme replacement therapy, and gene therapy.

Wiskott–Aldrich Syndrome Etiology and pathogenesis. Wiskott–Aldrich syndrome is an X-linked

immunodeficiency disorder occurring only in males. It is caused by a mutation of the WAS protein (WASp) gene and has been mapped to the short arm of the X chromosome at Xpll.23. The WASp gene is

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spleen, Peyer patches, lymph nodes) are poorly developed. The disease is characterized by recurrent bacterial infection and profound hypogam- maglobulinemia resulting from decreased numbers of circulating B cells. Male infants affected by this disorder are typically diagnosed after the infant reaches 4 months of age because of passive maternal IgG protection.

Clinical manifestations and treatment. Patients exhibit failure to thrive and frequent serious infections. The infections are most often attributable to Haemophilus influenzae and S. pneumoniae, which cause pneumonia, otitis media, meningitis, sinusitis, and septicemia. The recurrent infections can lead to tissue destruction and injury. Many children die before the age of 6. If the child survives to adulthood, life expectancy is decreased. Chronic lung disease, large joint arthritis, and the development of B-cell malignancies occur in adults with XLA. Treatment of this disorder includes implementation of antibiotic therapy and prophylactic antibiotics, as well as monthly administration of immunoglobulin infusions. However, passive immunotherapy is not always effective. Currently, curative hematopoietic stem cell–based gene therapy is advocated to correct B-cell and myeloid deficiencies. Children who have been diagnosed with XLA should not be immunized with live virus vaccine due to the risk of the development of severe infection.

Transient Hypogammaglobulinemia Transient hypogammaglobulinemia of infancy is a self-limiting condition in which the infant is slow to acquire normal immunoglobulin levels. The infant experiences a lengthened period of low IgG, IgM, and IgA levels after birth. Normal IgG production begins only after 2 months of life and increases slowly as maternal immunoglobulins are metabolized. Affected infants usually demonstrate normal immunoglobulin levels and immune system function by between 18 and 30 months. During the period of low antibody levels, they are more susceptible to infections, particularly respiratory tract infections.

Common Variable Immunodeficiency Disease Common variable immunodeficiency disease (CVID) is a B-cell disorder characterized by low titers of immunoglobulins, particularly IgG and IgA, as well as abnormal specific antibody responses. The primary defect is the inability of B cells to differentiate into plasma cells. In most cases, there are multiple mutations in several genes that encode the production of antibody subclasses and cytokines. There are usually normal numbers of B cells. The onset of CVID disease is variable from early childhood to the second or third decade of life. Males and females are equally affected with an incidence of 1 in 30,000 people.

Clinical manifestations and treatment. CVID is characterized by recurrent and severe infections, particularly respiratory tract disorders, including sinusitis, otitis, laryngitis, and pneumonia. The most frequent pathogens involved are encapsulated bacteria such as S. pneumoniae and H. influenzae. Infections of the gastrointestinal tract also occur from Giardia and Salmonella. There is an increased incidence of associated autoimmune disorders, including autoimmune thrombocytopenia purpura, arthritis, or thyroiditis; malignancies such as lymphoma, gastric, or colon cancer; granulomas in multiple locations; and gastrointestinal diseases, including colitis. Treatment involves IV or subcutaneous administration of immunoglobulin every 2 to 4 weeks, use of corticosteroids, and prompt treatment with antibiotics as needed. Occasionally stem cell transplantation is used in treatment.

SECONDARY IMMUNODEFICIENCY DISORDERS A number of physical, psychosocial, nutritional, environmental, and pharmacologic factors can singly or in combination lead to the

Chronic Mucocutaneous Candidiasis Disease Etiology and pathogenesis. Chronic mucocutaneous candidiasis

disease (CMCD) is a T-cell disorder caused by an autosomal-dominant mutation affecting STAT 1 GOF with impaired-to-absent IL-17. CMCD results from the deficiency of the cytokine IL-17 or IL-17F, leading to selective susceptibility to fungal infections and Staphylococcus aureus. There is variability in impairment from complete to partial with varying cytokine activity. As a result of these deficiencies, CMCS is characterized by a selective deficiency of cell-mediated immunity against Candida albicans and S. aureus. In this case T cells do not produce the correct cytokines needed for the cell-mediated immunity to C. albicans. This causes persistent or recurrent isolated skin, nail, and mucous membrane infections. B-cell and T-cell functions are usually normal, except for the inability of the T cells to respond to Candida infections. Occasionally IgA or other antibody levels may be affected.

Clinical manifestations and treatment. The goal of treatment is to reduce the severity of skin and mucous membrane infections and to decrease the disfigurement from infection and scarring. Treatment involves antifungal therapy or antibiotic therapy. Gene therapies are being investigated.

B-Cell Disorders IgA Deficiency

Etiology and pathogenesis. The most common B-cell PID is selective IgA deficiency (SIgAD). The incidence of this disorder varies geographi- cally, affecting 1 in 600 persons in Caucasian populations and 1 in 2600 among Asian populations. It is a B-cell disorder characterized by either apoptosis of plasma cells or failure of IgA-bearing lymphocytes to become plasma cells. The result is the lack of IgA antibodies in the serum. Genetically, it can be an autosomal-recessive or autosomal-dominant disease. The B-cell level is normal, but there is a lack of B-cell response to cytokines (IL-4, IL-6, IL-7, IL-10). Serum levels of IgM and IgG, as well as T-cell numbers, are normal.

Clinical manifestations and treatment. People with this disorder may exhibit no symptoms. However, when symptoms occur, they are prone to respiratory, gastrointestinal, and genitourinary tract infections. They tend to have many autoantibodies (including anti-IgA antibodies) with a high incidence of allergic, vascular, endocrine, and collagen autoimmune diseases. They often react to cow’s milk, and inflammatory bowel conditions such as celiac disease can develop. Treatment includes prevention of infection and management of infection with appropriate antibiotics. SIgAD patients are at risk of developing anti-IgA antibodies when exposed to blood or blood products. As a result, exogenous IgA replacement is contraindicated. When blood is needed, washed and packed RBCs with volume expanders are used to avoid serum antibody exposure.

X-Linked Agammaglobulinemia Etiology and pathogenesis. X-linked agammaglobulinemia (XLA)

(also known as Bruton X-linked agammaglobulinemia) is a B-cell genetic disorder caused by a lack of normal B-cell development in the bone marrow. The disorder is linked to a mutation of the gene btk (Bruton tyrosine kinase) located on the long arm of the X chromosome at position Xq21.3 to Xq22. It occurs in about 1 : 200,000 male births. In 1952 it was the first genetic immunodeficiency disorder identified. Females are carriers. This mutation occurs in a cytoplasmic signal- transducing molecule encoded by the btk gene, which results in decreased or absent B cells. The low B-cell numbers cause decreased or absent serum concentrations of IgG, IgA, or IgM immunoglobulins. The number of T cells is normal. The thymus functions normally. Plasmocytes are absent, and reticuloendothelial tissue and lymphoid organs (e.g., tonsils,

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as well as carbohydrate, lipid, vitamin, and mineral deficiencies. Protein and calorie depletion causes T-cell reductions and dysfunction. Antibodies are composed of proteins, levels of which are also low in a state of depletion. Low levels of zinc, an enzyme cofactor needed for lymphocyte function, as well as low levels of folic acid and vitamins B6, A, D, and E, can result in T-cell and B-cell dysfunction. Obesity, low physical activity, and hyperlipidemia can cause chronic systemic inflammation due to local immune response in visceral adipose tissue. Obesity has been found to cause up-regulation of a wide variety of proinflammatory cytokines, including IL-5, IL-10, IL-12, and IFN-γ. Nutritional balance is best for the development of all stem cells, the recognition and process- ing of antigens, and the attainment of optimal immune cell function.

In the elderly, immune system function is altered with decreased response to antigenic stimulation. This decrease is due to increased CD8+ T cells that lack expression of the CD28 molecule. This subset (CD28-CD8+) does not respond well to antigenic stimulation. Immune system cells in the elderly are not able to proliferate or reproduce as effectively as in younger persons, making them less able to respond to “new” antigenic stimuli. Although the total number of T cells remains the same, T-cell function is decreased. T cells are less capable of proliferat- ing and have decreased cytotoxicity. Antibody production also decreases. A rise is seen in autoantibody production, which may influence the increase in autoimmune disease in the elderly.

development of secondary immunodeficiency disorders. Many of these linkages are discussed in Chapter 8.

The direct and indirect linkages between the brain and the endocrine and immune systems are well known. As a result, excessive or defective neuroendocrine responses can lead to disease. For example, an excessive neuroendocrine response to stress with increased secretion of corticosteroids boosts a person’s susceptibility to infectious agents and tumors but enhances resistance to autoimmune disease. On the other hand, a defective neuroendocrine response to stress with low corticosteroid levels enhances autoimmune disease and inhibits infections and tumors. Individuals experiencing physical and psychosocial stress, decreased social support, depression, and bereavement show decreased immune system functioning.

Morbidity and surgery also affect the function of the immune system. After surgery, T-cell and B-cell numbers decrease. This temporary deficiency can last up to 1 month and is most likely a result of the stress of surgery. Some types of surgery, such as splenic surgery, actually reduce the effectiveness of the immune system. Removal of the spleen reduces serum IgM and the antibody response to encapsulated bacteria (e.g., S. pneumoniae, H. influenzae, S. aureus). Disease states such as diabetes mellitus, drug- or alcohol-induced cirrhosis, severe burns, severe trauma, sickle cell anemia, malignancies, and severe infections are associated with secondary immune deficiencies. For example, when blood glucose level rises in patients with diabetes mellitus, white blood cell response to infection declines.

Pregnancy requires immune adaptation in order to be successful. During pregnancy, many factors are released from the placenta influencing the immune system, including B-cell and T-cell function and cytokine balance. The placenta functions to regulate and coordinate all of the components of the complex maternal and fetal immune interface such as the secretion of cytokines: proinflammatory and antiinflammatory.34 Pregnancy’s proinflammatory state requires careful coordination, and failure to adapt can lead to spontaneous abortion or preeclampsia. For example, exosomes (syncytiotrophoblast microvesicles) are shed from the placenta into the maternal circulation. These exosomes have both physiologic and immunologic functions.

A number of pharmaceuticals affect the functioning of the immune system. Cytotoxins and other cancer pharmacotherapeutic drugs cause a state of generalized immunosuppression, including growth retardation, susceptibility to infection, impaired wound healing, and hypertension. For example, methotrexate is a phase-specific cytotoxin in which cells are killed only if they are in the S, or DNA-synthetic, phase. Cyclophos- phamide is toxic to cells in any mitotic phase, although it is better at killing active cells. Anesthetics (e.g., halothane, cyclopropane, nitrous oxide, ether), alcohol, antibiotics, antithyroids, anticonvulsants, anti- histamines, and steroids decrease cellular or humoral immunity by various methods. For example, chronic nitrous oxide toxicity leads to cell-mediated immune deficits. Therapeutic radiation (x-rays) also affects the immune system by destroying rapidly proliferating cells. When T-cell and B-cell clones are needed, irradiation eliminates these cells, thus blunting or reducing the effectiveness of the body’s response.

A number of studies have linked immune system competency and nutritional status. Malnutritional states can lead to protein depletion,

KEY POINTS • Primary deficiencies in immune function may be from congenital, genetic,

or acquired defects that directly affect immune cell function. • Secondary deficiencies are conditions that impair immune function as a

result of other nonimmune system disorders, such as poor nutrition, pregnancy, stress, or drugs, that secondarily suppress immune function.

• Primary genetic immunodeficiency disorders are fairly common, with most causing moderate immune impairment that may not be diagnosed. Severe congenital immunodeficiency disorders are less common, but clinically sig- nificant. Impairment in T cells and B cells results in severe combined immu- nodeficiency (SCID). Functional B and T lymphocytes are lacking, and infants with SCID easily succumb to sepsis and opportunistic infections. Other types of primary immunodeficiency disorders (PIDs) affect a particular cell type: DiGeorge syndrome (now called 22q11.2 deletion syndrome) occurs with T-cell agenesis related to a lack of thymus function; chronic mucocutaneous candi- diasis is caused by abnormal T cells that cannot respond to Candida; and selective immunoglobulin A (IgA) deficiency is caused by B-cell abnormality.

• Problems in neuroendocrine and immune system interactions are a cause of secondary immunodeficiencies. Excessive neuroendocrine response to stress with increased corticosteroid production increases susceptibility to infection.

• Medications such as cytotoxins and other cancer pharmacotherapeutic drugs cause generalized secondary immunosuppression. However, other medica- tions, such as anesthetics, alcohol, antibiotics, and steroids, also affect the immune response and can lead to secondary immunosuppression.

• Malnutrition, a major cause of immune system dysfunction, leads to lym- phocyte dysfunction and altered stem cell development.

Human beings live in internal and external environments teeming with antigens capable of producing immunologic responses. Contact with an antigen, or antigens, usually leads to induction of a normal protective immune response. However, some individuals experience disease and tissue damage caused by either excessive or deficient immune responses.

Excessive immune reactions are common and involve a complex interplay between antigen and components of the immune system. Autoimmune disease is a type of excessive immune reaction in which the immune system reacts against the body’s own cells, such as in rheumatoid arthritis or Graves disease. The tissues that are affected in

S U M M A R Y

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excessive immune reactions depend on the type of antigen, the type of antigen exposure, and the degree of immune responsiveness. Hyper- sensitivity disorders are differentiated by the cell type involved and the time course of the reaction. For example, type I hypersensitivity is a rapid response caused by a host of lethal chemicals generated by but involving only one antibody, IgE, and one effector cell, the mast cell. It is an antigen–antibody reaction causing the release of potent chemicals that can lead to extreme, even life-threatening, anaphylaxis reactions in susceptible individuals.

Deficient immune reactions are caused by genetic or embryonic defects. The lack of or dysfunction of T cells, B cells, and antibodies can lead to lethal or recurrent infections or other diseases that severely

limit the patient’s ability to interact with the environment. The degree of immune system dysfunction or deficiency varies greatly between individuals due to the complex interaction between the various com- ponents of the immune system. For example, the most common type of deficient immune response is SIgA. As a result of variable IgA produc- tion by B cells, the range of symptoms varies from none to recurrent infections with autoimmune disease.

Research into the complex interaction between genetic factors, environmental factors, and the immune system is ongoing. We are challenged to expand our understanding and knowledge of immune components, responses, and their physiologic or pathologic effects on individuals, families, and society as a whole.

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Malignant Disorders of White Blood Cells Marie L. Kotter and Jacquelyn L. Banasik

K E Y Q U E S T I O N S • How do the various types of leukemia, lymphoma, and plasma

cell myelomas differ based on the type of malignant transformation?

• How do the clinical presentations, prognosis, and management of types of acute and chronic leukemia differ?

• Why are malignant disorders of white blood cells commonly associated with bone marrow depression?

• How is Hodgkin disease clinically and histologically differentiated from other types of lymphoma?

• What is the purpose and process of staging procedures for lymphomas?

• What clinical and laboratory findings would suggest a diagnosis of plasma cell myeloma?

C H A P T E R O U T L I N E Classification of Hematologic Neoplasms, 215 Etiology of Myeloid and Lymphoid Neoplasms, 216 General Principles of Management, 217

Diagnosis of Hematologic Neoplasms, 217

Principles of Treatment, 218

Prevention and Management of Complications, 219

Myeloid Neoplasms, 221 Chronic Myeloid Leukemia, 221

Acute Myeloid Leukemia, 222

Lymphoid Neoplasms, 223 Chronic Lymphoid Leukemia, 223

Acute Lymphoblastic Leukemia/Lymphoma, 223

Hairy Cell Leukemia, 224

Plasma Cell Myeloma (Multiple Myeloma), 224

Hodgkin Disease, 227

B-Cell, T-Cell, and NK-Cell Lymphoma (Non-Hodgkin), 229

http://evolve.elsevier.com/Banasik/pathophysiology/

Leukemia, lymphoma, and plasma cell myeloma (multiple myeloma) are common neoplastic disorders of the bone marrow and lymphoid tissues. Depending on the location and specific types of white blood cells involved, these malignancies can be further divided into a number of specific subtypes. Leukemias can be conceptualized as circulating tumors that are disseminated from the beginning of the disease process and primarily involve the blood and bone marrow. Lymphoma tends to localize in lymph tissues, but is often disseminated to other sites at the time of diagnosis. Plasma cell myeloma is a malignant transformation of B-lymphocyte plasma cells and has a predilection to form localized tumors in bony structures.

Malignancies of the blood-forming tissues and lymphatic structures often present with nonspecific symptoms. Malaise, weakness, unexplained fever, night sweats, and recurrent infections should raise suspicion of malignancy. Enlarged, nontender lymph nodes (lymphadenopathy) are a common finding in lymphoma and some leukemias. Often, white blood cell malignancies are found by chance during routine assessment of the complete blood cell count (CBC). A very high total white blood cell count or the presence of abnormal cell types should precipitate an

assessment for hematologic cell malignancy. In general, earlier detection of malignancy is associated with a better prognosis for cure.

CLASSIFICATION OF HEMATOLOGIC NEOPLASMS Various classification schemes have been used to group hematologic neoplasms, with clinicians favoring schemes that use clinical findings and pathologists preferring morphologic criteria. With the advent of technolo- gies to identify specific genetic alterations and molecular characteristics of neoplastic cells, the traditional classification systems have become less useful. However, many clinicians and organizations, such as the American Cancer Society, continue to use traditional groupings to collect statistics and to provide information to the public. The approach used in this chapter incorporates the most recent World Health Organization (WHO) classifications for hematologic neoplasms and includes common clinical terminology. A major force behind the adoption of the WHO classification is the recognition that lymphoid leukemias and lymphomas are not separate disorders, but represent different stages of the same biological disease. Thus the major categories of the WHO system are

• Review Questions and Answers • Glossary (with audio pronunciations for selected terms) • Animations

• Case Studies • Key Points Review

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ETIOLOGY OF MYELOID AND LYMPHOID NEOPLASMS As in other malignant processes, the exact cause of hematologic neoplasms is unknown. The basic mechanism of malignant transformation involves mutation of cells, which disrupts growth control and differentiation pathways. These processes are thought to be similar to those described for solid tumors (see Chapter 7). A number of specific genetic mutations have been found for several hematologic malignancies. In some cases, these specific mutations indicate prognosis of the disease, and in others they may provide a target for therapy. Monoclonal antibodies have been developed to attach to products of some of these mutated genes, thus allowing therapy to be more targeted to the abnormal cells.

Viruses have long been suspected as mutagenic agents in some neoplasms, particularly retroviruses and herpesviruses. Close associations have been found between a small number of viruses and particular malignancies. For example, human T-cell leukemia virus (HTLV-1) is

based on the cell type of the neoplasm rather than its location in the body. Neoplasms involving cells of the myeloid lineage (Box 11.1) are separated from those of the lymphoid lineage (Box 11.2). The myeloid lineage includes red blood cells, platelets, monocytes, and granulocytes; the lymphoid lineage includes B cells, T cells, and natural killer (NK) cells (Fig. 11.1). There are four major categories of myeloid neoplasms: myeloproliferative diseases, myelodysplastic/proliferative diseases, myelo- dysplastic syndromes, and acute myeloid leukemia (AML). There are three major categories of lymphoid neoplasms: B-cell neoplasm, T-cell and NK-cell neoplasm, and Hodgkin disease. The term non-Hodgkin lymphoma is still in clinical usage and refers to lymphomas of B-cell, T-cell, and NK-cell origin. Non-Hodgkin lymphoma includes such a large and diverse group of malignancies that it has little relevance to prognosis or treatment. The WHO classification does not use this term. There are many etiologic, pathogenic, and treatment similarities among the hematologic malignancies, and these are addressed in a general way first, followed by sections concentrating on specific diseases.

From Arber DA et al: The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia. Blood 2016;127(20):2391–2404.

Myeloproliferative Neoplasms (MPN) Chronic myeloid leukemia (CML), BCR-ABL1+

Chronic neutrophilic leukemia (CNL) Polycythemia vera (PV) Primary myelofibrosis (PMF)

PMF, prefibrotic/early stage PMF, overt fibrotic stage

Essential thrombocythemia (ET) Chronic eosinophilic leukemia, not otherwise specified (NOS) MPN, unclassifiable Mastocytosis

Myeloid/Lymphoid Neoplasms With Eosinophilia and Rearrangement of PDGFRA, PDGFRB, or FGFR1, or with PCM1-JAK2 Myeloid/lymphoid neoplasms with PDGFRA rearrangement Myeloid/lymphoid neoplasms with PDGFRB rearrangement Myeloid/lymphoid neoplasms with FGFR1 rearrangement Provisional entity: Myeloid/lymphoid neoplasms with PCM1-JAK2

Myelodysplastic/Myeloproliferative Neoplasms (MDS/MPN) Chronic myelomonocytic leukemia (CMML) Atypical chronic myeloid leukemia (aCML), BCR-ABL1−

Juvenile myelomonocytic leukemia (JMML) MDS/MPN with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T) MDS/MPN, unclassifiable

Myelodysplastic Syndromes (MDS) MDS with single lineage dysplasia MDS with ring sideroblasts (MDS-RS)

MDS-RS and single lineage dysplasia MDS-RS and multilineage dysplasia

MDS with multilineage dysplasia MDS with excess blasts MDS with isolated del(5q) MDS, unclassifiable Provisional entity: Refractory cytopenia of childhood Myeloid neoplasms with germ line predisposition

Blastic Plasmacytoid Dendritic Cell Neoplasm

Acute Myeloid Leukemia (AML) and Related Neoplasms AML with recurrent genetic abnormalities AML with t(8;21)(q22;q22.1);RUNX1-RUNX1T1 AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22);CBFB-MYH11 APL with PML-RARA AML with t(9;11)(p21.3;q23.3);MLLT3-KMT2A AML with t(6;9)(p23;q34.1);DEK-NUP214 AML with inv(3)(q21.3q26.2) or t(3;3)(q21.3;q26.2); GATA2, MECOM AML (megakaryoblastic) with t(1;22)(p13.3;q13.3);RBM15-MKL1 Provisional entity: AML with BCR-ABL1 AML with mutated NPM1 AML with biallelic mutations of CEBPA Provisional entity: AML with mutated RUNX1 AML with myelodysplasia-related changes Therapy-related myeloid neoplasms AML, NOS

AML with minimal differentiation AML without maturation AML with maturation Acute myelomonocytic leukemia Acute monoblastic/monocytic leukemia Pure erythroid leukemia Acute megakaryoblastic leukemia Acute basophilic leukemia Acute panmyelosis with myelofibrosis

Myeloid sarcoma Myeloid proliferations related to Down syndrome

Transient abnormal myelopoiesis (TAM) Myeloid leukemia associated with Down syndrome

Acute Leukemias of Ambiguous Lineage Acute undifferentiated leukemia Mixed phenotype acute leukemia (MPAL) with t(9;22)(q34.1;q11.2); BCR-ABL1 MPAL with t(v;11q23.3); KMT2A rearranged MPAL, B/myeloid, NOS MPAL, T/myeloid, NOS

BOX 11.1 WHO Classification of Myeloid Neoplasms

CHAPTER 11 Malignant Disorders of White Blood Cells 217

immune function are also believed to predispose to the emergence of malignancies.

A number of disease conditions have been linked to the develop- ment of leukemia, although the mechanisms are unclear. A reduction or alteration in normal hematopoiesis, as occurs in such disorders as Fanconi anemia and aplastic anemia (see Chapter 13), is associated with a higher incidence of leukemia. A higher risk also has been noted in some genetic diseases, including Down syndrome and Klinefelter syndrome (see Chapter 6).

GENERAL PRINCIPLES OF MANAGEMENT Diagnosis of Hematologic Neoplasms Manifestations of hematologic neoplasms vary somewhat, depending on the cell type involved. Common manifestations are shown in Box 11.3. Clinical symptoms are related to bone marrow suppression and organ dysfunction secondary to leukemic infiltration. Bone marrow suppression results in varying degrees of leukopenia, anemia, and thrombocytopenia. These three deficiencies cause the most common clinical manifestations and may prompt the patient to seek care.

Anemia, with a hematocrit level of 25% to 30% or a hemoglobin level of 8 to 10 g/dL, may manifest with pallor, fatigue, malaise, shortness of breath, and decreased activity tolerance. The severity of symptoms is determined by the rate of red blood cell decrease, as well as the absolute deficiency. Chronically low hemoglobin and hematocrit values may be better tolerated than a drastic drop in these measurements. Depending on symptoms, transfusion may be indicated when the hematocrit level falls below 30%.

Thrombocytopenia, with a platelet count less than 20,000 cells/µL, can manifest as petechiae, easy bruising, bleeding gums, occult hematuria,

From Hoffbrand AV, Moss PAH: World Health Organization classification of tumours of the haematopoietic and lymphoid tissues. In Essential haematology, ed 6, Oxford, England, 2011, Blackwell, pp 428–429.

Precursor Lymphoid Neoplasms Precursor B lymphoblastic leukemia/lymphomas (precursor B-cell ALL) Precursor T lymphoblastic leukemia/lymphoma

Mature (Peripheral) B-Cell Neoplasms* B cell chronic lymphocytic leukemia/small lymphocytic lymphoma B cell prolymphocytic leukemia Lymphoplasmacytic lymphoma Splenic marginal zone B-cell lymphoma (6 villous lymphocytes) Hairy cell leukemia variant Plasma cell myeloma/plasmacytoma Waldenström macroglobulinemia Heavy-chain diseases Extranodal marginal zone B-cell lymphoma of MALT type Nodal marginal zone B-cell lymphoma (6 monocytoid B cells) Follicular lymphoma Mantle cell lymphoma Epstein-Barr virus positive DLBCL of the elderly Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease Primary mediastinal (thymic) large B-cell lymphoma Primary effusion lymphoma Burkitt lymphoma/Burkitt cell leukemia

Mature T-Cell and NK-Cell Neoplasms Mature (peripheral) T-cell neoplasms

T-cell prolymphocytic leukemia T-cell granular lymphocytic leukemia

Aggressive NK-cell leukemia Adult T-cell lymphoma/leukemia (HTLV1+) Extranodal NK/T-cell lymphoma, nasal type Enteropathy-type T-cell lymphoma Hepatosplenic γδ T-cell lymphoma Subcutaneous panniculitis-like T-cell lymphoma Mycosis fungoides Sézary syndrome Primary cutaneous anaplastic large cell lymphoma Peripheral T-cell lymphoma, not otherwise characterized Angioimmunoblastic T-cell lymphoma Anaplastic large cell lymphomas (ALK positive or ALK negative)

Hodgkin Lymphoma (Hodgkin Disease) Nodular lymphocyte predominance Hodgkin lymphoma Classical Hodgkin lymphoma Nodular sclerosis Hodgkin lymphoma (Grades 1 and 2) Lymphocyte-rich classical Hodgkin lymphoma Mixed cellularity Hodgkin lymphoma Lymphocyte depletion Hodgkin lymphoma

BOX 11.2 WHO Classification of Lymphoid Neoplasms

*B- and T/NK-cell neoplasms are grouped according to major clinical presentations (predominantly disseminated/leukemic, primary extranodal, predominantly nodal).

linked to the development of adult T-cell lymphoma/leukemia, and human immunodeficiency virus (HIV) is linked to B-cell lymphomas. Epstein–Barr virus (EBV) has been implicated in both Hodgkin disease and Burkitt lymphoma. Effective immune surveillance is thought to keep proliferation in check and prevent progression in immunocompetent individuals.

Radiation exposure is an important etiologic factor for leukemia and lymphoma. Because of the relatively high turnover of hematologic cells, they are more susceptible to radiation-induced damage than most other cell types. An acute whole-body dose of radiation, like that which occurs with nuclear explosions, is known to increase the risk of leukemia. In Japanese survivors of the atomic bomb, the estimated lifetime risk of leukemia is 0.85%, sixfold higher than the norm. There are substantial uncertainties about the risk of low-level, long-term exposure to radiation. The average annual exposure from usual sources, including cosmic rays and medical procedures, is very low and is estimated to account for less than 5% of leukemia cases.

Despite intensive scrutiny only a small number of chemicals have been shown unequivocally to increase the risk of hematologic malignan- cies. Benzene has been implicated in numerous studies, as has cigarette smoking. Other suggested carcinogens have failed to be confirmed, including exposure to hair dye, alcohol, and marijuana. On the other hand, a study from the Children’s Cancer Group found a link between high maternal intake of products high in bioflavonoids (beans, fresh vegetables, and fruit) and an increased incidence of infant leukemia. These bioflavonoids were enzyme inhibitors (topoisomerase II inhibitors) that caused DNA cleavage and chromosome translocations. Many of the antineoplastic drugs used to treat cancers, especially the alkylating agents, are significant factors in the development of posttreatment hematologic neoplasia. Any drugs that suppress the bone marrow or

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monitored. Neutropenia is an absolute neutrophil count less than 500 cells/µL, and an affected patient requires protective isolation (neutropenic precautions) to prevent infection. Infections may be caused by bacterial, viral, fungal, or protozoal organisms. Often, the microorganisms are of the opportunistic variety. That is, they are part of the patient’s own flora, which normally do not cause disease unless the host’s immune system becomes incompetent. It is very difficult to protect patients from their own flora, and infection is the most common cause of death in the immunocompromised leukemic patient. The presence of infection is suspected if fever develops. Infections are managed aggressively with antibiotic agents to prevent development of life-threatening sepsis.

Infiltrative manifestations include lymphadenopathy, joint swelling and pain, weight loss, anorexia, hepatomegaly, and splenomegaly. Sternal tenderness is frequently present in chronic myeloid leukemia (CML). Gingival hyperplasia occurs in AML. Meningeal involvement is frequently encountered in children with acute lymphoid leukemia (ALL). Central nervous system (CNS) infiltration can occur with any type of leukemia and may be difficult to manage because of the poor ability of chemo- therapeutic agents to cross the blood–brain barrier. CNS involvement can present with increased intracranial pressure, seizures, or changes in mental ability. Increased intracranial pressure should be suspected in the leukemia patient who complains of nausea, vomiting, headache, and visual changes.

A key aspect of diagnosis is the evaluation of a peripheral blood sample. Blood cell number and morphologic evaluation are indicative; however, definitive diagnosis is usually made after bone marrow aspiration or lymph node biopsy. Malignant cells can be subtyped according to genetic and molecular characteristics to better determine prognosis and choice of treatment.

Principles of Treatment To make informed treatment decisions, patients and their families need information about the nature and prognosis of their disease, as well as about the risks and benefits of various treatment options. Many treatment protocols are experimental, and the outcomes may be uncertain. Sometimes the side effects of treatment, as well as its limited efficacy, will weigh in favor of palliative care. Treatment decisions are complex

Lymphoid stem cell

Myeloid stem cell

Stem cell

B-cell leukemia/

lymphoma/ myeloma

NK-cell leukemia/ lymphoma

T-cell leukemia/ lymphoma

Granulocytic leukemia

Monocytic leukemia

PV/ erythroid leukemia

Essential thrombocythemia/ megakaryocytic

leukemia

Lymphoid Neoplasms Myeloid Neoplasms

B cellNK cell T cell Neutrophil RBC MegakaryocyteMonocyte

FIG 11.1 Division of hematologic neoplasms into myeloid and lymphoid lineages. PV, Polycythemia vera.

History Fever Weight loss Night sweats Itching (pruritus) Fatigue Bone pain (sternum, tibia, femur, back) Abdominal fullness Bleeding episodes (epistaxis, menorrhagia) Bruising, petechiae Frequent infections Headache, nausea, vomiting

Physical Enlarged spleen Enlarged liver Enlarged lymph nodes Hyperplasia of gums

Laboratory Anemia or polycythemia Thrombocytopenia or thrombocythemia Leukopenia or leukocytosis Blasts on peripheral blood smear Elevated uric acid level Elevated alkaline phosphatase level Hypercalcemia

BOX 11.3 Common Manifestations of Hematologic Malignancies

or retinal hemorrhages. Spontaneous intracranial bleeding can occur and may be fatal. In general, the risk of bleeding increases proportionately to the fall in platelet count. Platelet transfusion may be given when the risk of bleeding is high.

Insufficient numbers of functional leukocytes leave the patient at high risk for development of infection, and the CBC is routinely

CHAPTER 11 Malignant Disorders of White Blood Cells 219

profoundly affect the outcome of chemotherapy. The length of time that a patient remains neutropenic can be shortened with the use of growth factors to stimulate bone marrow production of granulocytes.

Bone marrow transplantation has been an important part of the management of certain leukemias for many years. The intense chemo- therapy used to induce remission can lead to bone marrow failure. Stem cells can be reintroduced into the host’s bone marrow by bone marrow transplantation. The transplanted cells are given intravenously; they find their way to the host’s bone marrow, where they establish residence and begin to produce functional white blood cells, red blood cells, and platelets. A close match between donor and host is necessary for a successful transplantation. Otherwise, the transplanted cells can mount an immune attack on the host’s tissues—a life-threatening problem called graft-versus-host disease (see Chapter 10). In past years, the transplant was obtained by aspiration from the marrow of a suitable donor, and this may still be done in some cases. Peripheral stem cell transplantation allows stem cells to be harvested from the circulating bloodstream. This procedure can be used to collect stem cells from the patient’s own blood to be stored and then reinfused after chemotherapy and irradiation. This type of transplant is called autologous, whereas a transplant from a closely matched relative is called allogeneic (Fig. 11.2). Use of autologous transplants eliminates the problem of graft-versus-host disease and reduces transplant-related mortality, but the potential for disease recurrence is higher than with allogeneic transplants.

It has been noted that in AML and CML, transplantation with allogeneic cells is much more successful in curing leukemia than is autologous transplantation. Transplanted cells in the allograft are thought to detect and kill leukemic cells in a process termed graft versus leukemia. Autologous transplants are appropriate in some cases, especially when a matched donor is not available, because they may extend life even though cure is unlikely. Autologous transplants are well tolerated and cause fewer complications than allografts. Methods to purify a patient’s collected peripheral blood by selectively removing neoplastic cells are available to reduce the risk of reintroducing malignant cells during autologous transplantation. Increased availability of stem cell transplants allows patients to undergo more intensive chemotherapy, aimed at cure rather than palliation, based on the knowledge that bone marrow rescue is possible.

Anemia is a common complication of leukemia and chemotherapy. Red blood cell production by the bone marrow is suppressed, but the size and shape of red blood cells present in the blood are normal. This is called normocytic, normochromic anemia. Administration of eryth- ropoietin growth factors can enhance red blood cell production and moderate anemic episodes. However, patients frequently require red blood cell transfusion therapy to maintain adequate red blood cell counts. Patients with frequent or significant bleeding episodes are also predisposed to severe anemia, and efforts to prevent bleeding will help minimize anemia.

Platelet deficiency (thrombocytopenia) with resultant hemorrhage can be a life-threatening complication of leukemia and chemotherapy. In patients at high risk of bleeding, fresh frozen plasma or pooled platelets may be given to inhibit bleeding. Patients must be protected from trauma and may be placed on activity restrictions.

Pain is a common complication of the diagnostic and treatment protocols used in the cancer patient as well as of the disease process itself. Pain most commonly involves the bones and joints, and is due to pressure caused by infiltration and accumulation of neoplastic cells in the bone marrow. Hemarthrosis (bleeding into joints) can cause acute episodes of joint pain. Chemotherapy may help reduce bone pain, as the number of neoplastic cells is reduced drastically. Patients are subjected to numerous painful procedures during diagnosis, treatment, and monitoring. Frequent collection of blood and bone marrow samples,

and stressful for all concerned. A great deal of support must be available during the diagnostic, treatment, and monitoring phases.

The management of hematologic malignancies relies primarily on the use of combination chemotherapy to eradicate malignant cells and stem cell transplant to rescue and restore bone marrow function. In some cases radiation and tissue-specific drug therapy may be indicated. Unfortunately, the treatment regimen usually causes many serious side effects that must be monitored and treated.

The goal of chemotherapy is to induce long-term remission, that is, the absence of any detectable neoplastic cells in the body. A complete remission (CR) is defined as a return to normal hematopoiesis with normal red blood cell, neutrophil, and platelet counts and no detectable neoplastic cells. For leukemia, the bone marrow must have less than 5% blasts, which are the most immature bone marrow cells, and be maintained for at least 4 weeks. CR is not synonymous with cure. Therefore most treatment protocols include several cycles of chemo- therapy to eradicate the undetected cells. The choice of antineoplastic agents varies with the type of neoplasia and the stage of clinical disease. Most chemotherapeutic agents work by disrupting some aspect of DNA synthesis or cell replication and induce apoptosis (cell death; see Chapter 4). In general, rapidly dividing cells are more susceptible to apoptosis because they have less time for repair. Neoplasms with genetic defects that impair apoptotic pathways may be more difficult to eradicate and require more intense therapy. Unfortunately, these high doses are toxic to normal stem cells as well and can produce fatal bone marrow failure. Therefore to effect a cure, high-dose chemotherapy is often followed by bone marrow “rescue” with transplantation of functional stem cells.

Chemotherapy usually includes two or three treatment phases: (1) remission induction phase, (2) postremission or consolidation phase, and (3) remission maintenance phase. The aim of treatment during the remission induction phase is to eliminate all detectable neoplastic cells and achieve a CR. Postremission consolidation therapy begins after CR is attained in an attempt to eliminate the population of undetected cells that may have escaped initial induction phase treatment. Mainte- nance phase treatment is used in the management of some neoplasms to prolong the remission interval. Intermittent chemotherapy may be continued for 2 to 3 years after initial induction of remission. Drugs that target the neoplastic cells specifically, such as monoclonal antibodies or molecular therapies, are generally less toxic than other agents and may be used for long-term maintenance in patients with residual disease.

In children and adults, the CNS can act as a sanctuary for neoplastic cells in diseases such as ALL and AML. This makes conventional routes of chemotherapy unsuccessful, because they do not permit drugs to cross the blood–brain barrier efficiently. Chemotherapeutic agents administered into the cerebrospinal fluid via lumbar puncture (intrathecal route) can effectively eliminate leukemic cells in the CNS. This therapy carries significant risk for temporary or permanent neurologic damage. A number of different chemotherapeutic agents can be administered safely by the intrathecal route, including methotrexate.

Prevention and Management of Complications Maintenance of adequate nutrition in patients with hematologic malignancy is a major challenge. Anorexia, weight loss, nausea, vomiting, and stomatitis are common findings, especially during the treatment phase. Children and adolescents receiving chemotherapy may experience significant growth delay, and measures to maintain protein and caloric intake are necessary. Newer antiemetic agents have been helpful in reducing nausea, vomiting, and anorexia associated with chemotherapy and should be considered in patients experiencing these symptoms.

Infection is the most troublesome complication for the patient who is immunosuppressed by either disease or treatments. Constant vigilance in prevention, early detection, and rapid management of infections can

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placement of intravenous access lines for drug administration, and manifestations of unpleasant drug side effects all contribute to the pain experience. Nausea and mouth pain (stomatitis) are frequent complaints during chemotherapy. Pain management with a variety of strategies, including narcotic and nonnarcotic drugs, distraction, and biofeedback, is generally helpful. (See Chapter 47 for a discussion of pain and pain management.)

Epithelial cells, with normally high rates of turnover, are particularly susceptible to damage by radiation and chemotherapy. Sloughing of skin and mucous membranes and hair loss (alopecia) are common. Loss of skin and mucous membrane integrity increases the risk of infection and can contribute significantly to the pain and discomfort of treatment. Abnormalities in growth, development, and fertility are complications of particular concern in children undergoing radiation and chemotherapy.

ALLOGENEIC

Donor (related or unrelated) Treatment

Recipient (patient)

Blood/marrow processing; may include T cell depletion

Conditioning: • High-dose cyclophosphamide • Total body irradiation

Conditioning: • High-dose cyclophosphamide • Total body irradiation

Blood/ marrow infusion

RecipientRecipient (patient)

AUTOLOGOUS

Peripheral blood stem cells collected or bone marrow harvested

1

2

3 4 Blood/marrow infusion

RecipientRecipient (patient)

3 4

Blood/marrow processing and storage; may include purging

Peripheral blood stem cells collected or bone marrow harvested

1

2

FIG 11.2 Procedures for allogeneic and autologous stem cell transplantation. For nonmyeloblative (reduced intensity) allogeneic stem cell transplantation, lower doses of chemotherapy, with or without radiotherapy, are used. (From Rodak B et al: Hematology: clinical principles and application, ed 4, Philadelphia, 2012, Saunders.)

KEY POINTS • Classification of the types of leukemia is based on cell type involved (lymphoid

or myeloid) and degree of cell maturation. Common myeloid neoplasms include Chronic myeloid leukemia (CML), polycythemia vera (PV), essential thrombocythemia (ET), and acute myeloid leukemia (AML). Common lymphoid neoplasms include chronic lymphoid leukemia (CLL), acute lymphoid leukemia

(ALL), plasma cell myeloma, Hodgkin disease, and various forms of non- Hodgkin lymphoma.

• Risk factors for the development of hematologic neoplasms include exposure to chemical, viral, and radiation mutagens; consequences of chemotherapy drugs; and effects of immunodeficiency disorders.

• Common manifestations of hematologic neoplasia are due to insufficient produc- tion of normal white blood cells, red blood cells, and platelets, as evidenced by leukopenia, anemia, and thrombocytopenia. Anemia manifests as pallor, fatigue, dyspnea, and decreased activity tolerance. Thrombocytopenia causes petechiae, bleeding gums, hematuria, and prolonged bleeding time. Leukopenia manifests as frequent, recurrent infections. Other manifestations may occur with infiltration of tissues and organs. These include weight loss, anorexia, lymphadenopathy, bone pain, and central nervous system (CNS) dysfunction.

• Chemotherapy is the mainstay of management for most hematologic neoplasms. Several courses may be needed to kill neoplastic stem cells. Most chemotherapeutic agents interfere with some aspect of DNA replication and cell division to induce apoptosis (programmed cell death).

• Treatment is associated with a number of potential complications, including anemia, infection, and bleeding. Rapidly dividing hair cells and mucous membranes are also affected, leading to alopecia and stomatitis. Transfusion of blood products or stimulation of endogenous production with colony-stim- ulating factors and erythropoietin may be necessary. Bone marrow transplanta- tion may be undertaken in some cases to restore stem cell function.

CHAPTER 11 Malignant Disorders of White Blood Cells 221

the Philadelphia chromosome (Ph+). The Philadelphia chromosome is formed because of a balanced translocation between chromosomes 9 and 22 (Fig. 11.4). The translocation causes two genes to be juxtaposed, resulting in a new fusion gene called bcr-abl. This mutation is thought to be critical in the development of CML. Molecular studies have revealed that the protein product of the fusion gene is a functional enzyme that spurs cell proliferation and reduces apoptotic cell death. CML is unusual among human cancers because a single oncogene (bcr/abl) is capable of conferring a malignant state. Numerous mutations are necessary for development of most other cancers (see Chapter 7). The cells in CML are more mature than those found in AML, as noted by the greater degree of nuclear segmentation (Fig. 11.5).

The usual clinical presentation of CML includes a high granulocyte count on the CBC and splenomegaly. Symptoms, when present, may include fatigue, weight loss, diaphoresis, bleeding, and abdominal discomfort from the enlarged spleen.

Prognosis and treatment. CML does not respond well to chemo- therapy. Although most patients will achieve a temporary remission, the overall survival time is poor. In untreated patients the median survival

NeutrophilRBC

Megakaryocyte

Myeloid stem cell

M4

M1

M3 M2

M5

M7

M6

MonocytePlatelets

FIG 11.3 Maturation pathways of myeloid cells showing the different types of leukemia associated with various stages of development. M1, M2, and M3 types result in granulocytic leukemia; M4 has characteristics of monocytic and granulocytic leukemia; M5 is monocytic; M6 is associ- ated with erythroid leukemia; and M7 is associated with megakaryocytic leukemia. RBC, Red blood cell.

MYELOID NEOPLASMS Myeloid neoplasms result from transformation and proliferation of a precursor stem cell in the bone marrow (Fig. 11.3). The progeny of the aberrant stem cell clone accumulate in the bone marrow and are released into the circulation. In many cases, the abnormal stem cell is multipotent and causes the overproduction of more than one cell type, resulting in myeloproliferative disease. The cells produced in myeloproliferative diseases are usually functional and have a normal morphologic appear- ance. The common myeloproliferative diseases are CML, PV, and ET, referring, respectively, to an excess of granulocytes, red blood cells, and platelets. These insidious and indolent disorders have few clinical symptoms and are commonly discovered on routine CBC analysis. Common features of CML, PV, and ET include involvement of a multipotent hematopoietic progenitor cell; hypercellularity of marrow; overproduction of one or more functional blood cells; chromosomal abnormalities involving chromosomes 1, 8, 9, 13, and 20; and eventual spontaneous conversion to AML or development of marrow fibrosis.

In contrast to the myeloproliferative diseases, the myelodysplastic syndromes and AML are characterized by neoplastic cells that are morphologically and functionally abnormal. The prognosis for myelo- dysplastic syndromes and AML is poor, and intensive treatment is necessary to extend life. AML and CML are described next. A discussion of PV and ET can be found in Chapters 13 and 14, respectively.

Chronic Myeloid Leukemia Pathogenesis and clinical manifestations. CML represents approxi-

mately 15% of all cases of leukemia in the United States. The average age of onset is between 40 and 50 years, and CML occurs only occasionally in childhood and adolescence. The majority of CML cases are characterized by malignant granulocytes that carry a unique chromosomal abnormality,

New bcr-abl fusion gene

Philadelphia chromosome

Myelogenous leukemia

9 922

bcr bcr abl

abl

FIG 11.4 Balanced translocation between chromosomes 9 and 22 results in the formation of a Philadelphia chromosome. The translocation causes two genes, abl and bcr, to become juxtaposed, resulting in a fusion gene. This fusion gene, bcr-abl, is thought to be essential for the develop- ment of chronic myeloid leukemia.

FIG 11.5 Peripheral blood smear from a patient with chronic myeloid leukemia (CML). Note that a greater degree of neutrophil segmentation is found in CML than in acute myelogenous leukemia (see Fig. 11.6), reflecting a more advanced stage of development. (From Hoffman R, et. al. Hematology: basic principles and practice, ed 6, Philadelphia, 2013, Saunders.)

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by morphologic characteristics, including myeloid cell of origin and degree of differentiation or maturation. Correct classification increases the accuracy of prognosis and may influence the choice of treatment.

AML presents in a manner very similar to that of ALL, and the two are difficult to distinguish by clinical findings alone. Acute leukemia causes bone pain, anemia, thrombocytopenia, and increased susceptibility to infection. The skin, the genitourinary and gastrointestinal systems, and the respiratory tract are common infection sites. The onset of symptoms is abrupt, with most patients seeking care within a few weeks of disease onset. The prognosis is much worse for AML than for ALL, with fewer than 50% of children and only about 25% of adults achieving long-term survival. An exception is the promyelocytic subtype of AML. Although it accounts for only 10% to 15% of AML cases, acute pro- myelocytic leukemia (APL) deserves special consideration because it is the most curable of all AML subtypes, with a 70% to 80% 5-year disease-free survival. APL is characterized by a chromosomal translocation between chromosomes 8 and 21, which forms a fusion gene called PML/RARα. The PML/RARα protein binds to a repressor complex in the cell nucleus and inhibits myeloid cell differentiation. RARα is a retinoic acid receptor that can be induced to release its inhibitory hold on differentiation when all-trans-retinoic acid (ATRA) is administered. Addition of ATRA to the chemotherapy management of patients with APL significantly improves disease-free survival (see Table 11.1 for a comparison of acute and chronic leukemias).

Prognosis and treatment. Treatment protocols for AML are increasingly incorporating the cytogenetic profile of the leukemic cells to individualize therapy and monitor response. Traditionally the management of AML has two phases: remission induction and consolidation/postremission. A CR is attempted in the remission induction phase, with an attempt to eliminate any undetected residual leukemic cells during the consolidation/postremission phase. Patients with AML who are able to complete only one or two cycles of their chemotherapy because of toxicity almost invariably have recurrence of leukemia even when CR was achieved. To induce remission, most protocols use two cycles of a combination of agents. Postremission therapy commonly includes high-dose Ara-C in younger patients, whereas the elderly require lower-dose regimens. Drug treatment is constantly being evaluated and altered to obtain better outcomes. With the advent of allogeneic stem cell transplantation, the chances for a cure may improve; however, procedure-related mortality is 10% to 25%. New therapies using monoclonal antibodies to detect and destroy leukemic cells have been used and show promise for improving outcomes in AML.

is about 2 years. After discovery of the fusion protein (bcr/abl), drugs targeted to inhibit its action were developed (e.g., imatinib). The goal of anti-bcr/abl therapy is to reduce the number of leukemic cells with the bcr/abl phenotype to undetectable levels. It is not known whether imatinib can cure CML or what duration of treatment is necessary to permanently suppress the leukemic cell population. Some patients with CML have developed drug resistance against imatinib, and research is ongoing. The only known curative treatment is allogeneic bone marrow transplantation from a suitable donor. It is believed that the donor cells detect and kill the host’s leukemic cells. Even with a human leukocyte antigen (HLA)–identical sibling donor, the probability of transplant- related mortality is about 25%, and the likelihood of long-term disease- free survival is 50% to 60%. Transplant-related mortality is about 50% if the HLA-matched donor is unrelated. Bone marrow transplantation with cells harvested from the patient’s own blood (autografting) during the early stages of CML may also be done, but it is less effective in curing the disease. For those not able to undergo stem cell transplantation, standard chemotherapy during the chronic phase may be instituted. Once CML has progressed to the blast phase, essentially becoming AML, the prognosis is poor, regardless of treatment, with an expected median survival of 3 to 4 months.

Acute Myeloid Leukemia Pathogenesis and clinical manifestations. AML is primarily a disease

of adults, comprising 80% of cases of acute leukemia in this population but accounting for only 20% of the cases of acute leukemia of child- hood. The median age at presentation is 64 years. Like CML, AML is a malignant disorder associated with transformation of a myeloid stem cell. The bone marrow aspirate must have more than 20% blasts to be classified as AML. AML can present in a variety of ways because of the potential for myeloid stem cells to produce different cell types. Thus AML has a number of subtypes. Acute granulocytic leukemia is the most common type of disorder, and the term is often used interchangeably with AML. Myeloblastic cells have a large, nonsegmented nucleus and fine chromatin (Fig. 11.6). AML is also subtyped according to genetic abnormalities. Worse outcomes are noted with loss of P53 or RB tumor suppressor gene function. Most are chromosomal translocations or inversions. If cytogenetic class is not apparent, then AML is classified

FIG 11.6 Peripheral blood smear showing typical cells of acute myelog- enous leukemia. (From Eric Jeandidier et. al, A cytogenetic study of 397 consecutive acute myeloid leukemia (AML) cases identified three with a t(7;21) associated with 5q abnormalities and exhibiting similar clinical and biological features, suggesting a new, rare AML entity. Cancer Genetics, 2012;205(7):365–372.)

TABLE 11.1 Comparison of Acute and Chronic Leukemias

Acute Chronic

Age All ages Adult Clinical onset Sudden Insidious Course of untreated disease Weeks to months Months to years Predominant cell Blasts, some mature

forms Mature forms

Anemia Mild to severe Mild Thrombocytopenia Mild to severe Mild WBC count Variable Increased

Adopted from McKenzie S: Clinical laboratory hematology, Upper Saddle River, NJ, 2004, Pearson, p 482.

CHAPTER 11 Malignant Disorders of White Blood Cells 223

Chronic Lymphoid Leukemia Pathogenesis and clinical manifestations. CLL accounts for about

30% of all cases of leukemia in the United States. In 95% of cases, a malignant B-cell precursor is at fault. Only 5% of cases of CLL are associated with T-cell transformation, but this type is more aggressive. In general, B-cell CLL follows an indolent course, which is usually asymptomatic. Often CLL is found by accident on routine blood count examinations. When CLL becomes symptomatic, patients may experience fatigue, weight loss, and anorexia. Because the leukemic B cells do not produce antibodies normally, an increased susceptibility to certain types of infection may occur. Malignant lymphocytes invade lymphoid tissues and bone marrow, disrupting function. Lymphoid invasion often presents as enlarged, painless lymph nodes (lymphadenopathy) or enlarged spleen (splenomegaly). Bone marrow infiltration reduces the production of other cells, including red blood cells and platelets. A typical slide of a bone marrow aspirate from a patient with CLL is shown in Fig. 11.8. Note the preponderance of lymphoid cells. CLL cells are characterized by defective apoptosis and therefore have extended life spans. They are derived from mature peripheral B cells (see Table 11.2 for a comparison of acute and chronic leukemias).

Prognosis and treatment. Certain genetic mutations confer better or worse prognosis. A mutation in the variable region of the immuno- globulin gene (IgV) is associated with a median survival of 24 years or more; those without this mutation have a median survival of less than 8 years. CLL cell types demonstrating short telomere lengths and P53 dysfunction have poor outcomes. Because the average age of patients with CLL is about 65 to 70 years, those with indolent disease may not be treated; they are more likely to die of another disorder rather than CLL. Patients with cell types likely to progress rapidly may receive chemotherapy to induce remission. Those without complete response may consider stem cell transplantation to prolong the duration of remission.

Acute Lymphoblastic Leukemia/Lymphoma Pathogenesis and clinical manifestations. ALL is a malignant

disorder of the lymphoid cell lineage. The great majority of cases are

KEY POINTS • Chronic myeloid leukemia (CML) is a myeloproliferative disorder that primarily

affects adults, has an insidious onset, and responds poorly to chemotherapy. Most cases of CML are characterized by the presence of a gene translocation (Philadelphia chromosome) that produces a fusion gene called bcr-abl. The product of this gene is thought to be responsible for producing the malignancy. This molecular abnormality is the target of new drug therapies to eliminate neoplastic cells. The prognosis of CML remains relatively poor, but may be improved with allogeneic bone marrow transplantation in which transplanted cells destroy leukemic cells.

• AML affects adults primarily, has an acute onset, responds fairly well to treatment, and has a prognosis somewhat worse than that of ALL. AML is usually a malignancy of granulocytes, although other myeloid cell types may be affected. Several gene abnormalities have been identified in AML that may indicate better or worse prognosis. The median survival of patients younger than 60 years is 30% to 40% at 4 years.

FIG 11.7 Maturation pathways of T and B lymphocytes showing the stages at which lymphocyte development is typically arrested in leukemia. Different markers are present on the surface of B cells and T cells at progressive stages of development, which are helpful in identifying the neoplastic cell type and maturity.

LYMPHOID NEOPLASMS The lymphoid neoplasms include malignant transformations of B cells, T cells, and NK cells. When present in blood and bone marrow, lymphoid neoplasms are called leukemias, and when they are localized in lymphoid tissues, they are called lymphomas. The location of lymphoid neoplasms is a consequence of the stage of the disease. The WHO classification uses cell type rather than stage to classify the lymphoid neoplasms, resulting in some difficulty with the traditional conceptualization of leukemias and lymphomas. The factors that determine whether a particular neoplastic cell will present as leukemia or as lymphoma are not presently known. Subcategories of the B-cell and T-cell/ NK-groups are based on the maturity of the neoplastic cells (see Box 11.2). The precursor cell neoplasms are characterized by cells that have arrested development in the early blast stage, whereas the mature cell neoplasms are more differentiated and often located in peripheral sites (Fig. 11.7).

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incidence occurs between the ages of 3 and 7 years. A second peak occurs in middle age. The onset of symptoms is abrupt, with common complaints of bone pain, bruising, fever, and infection. Children may refuse to walk, and their parents may report loss of appetite, fatigue, and abdominal pain. The spleen, liver, and lymph nodes may be enlarged from leukemic infiltration. A small number of children (3%) may present with CNS signs from leukemic infiltration of brain tissues.

Prognosis and treatment. ALL is highly curable in the pediatric population, but less so in adults. The 5-year survival rate is 85% in children and 30% to 50% in adults. Certain forms of ALL are more responsive to therapy. For example, children with the pre–B-cell type have a 90% cure rate, whereas those with mature B-cell or immature T-cell leukemia have a poorer prognosis.

Chemotherapy is used for remission induction. Postremission chemotherapy with or without stem cell transplantation is indicated for most patients. In general, adults with ALL require more intense therapy than children to achieve complete remission (CR). Monoclonal antibodies may be used in patients whose tumors express specific antigens.

Hairy Cell Leukemia Pathogenesis and clinical manifestations. Hairy cell leukemia is

a rare, chronic type of leukemia. The disease represents about 2% of adult leukemias, but it is of interest because of its highly treatable nature. The median age at presentation is about 55 years, and there is a 5-to-1 predominance of males. Hairy cell leukemia has a B-cell phenotype and is characterized by the presence of peculiar cells with hairlike projections on their surface (Fig. 11.10). At diagnosis, patients have hairy cells in the peripheral blood as well as reduced numbers of granulocytes, platelets, and red blood cells. Splenomegaly is a common finding, being present in 90% of patients.

Prognosis and treatment. Treatment may be instituted when a patient becomes symptomatic with an enlarged spleen, recurrent infection, bleeding disorder, or anemia. An appropriate chemotherapeutic protocol produces CR rates of 80%.

Plasma Cell Myeloma (Multiple Myeloma) Pathogenesis and clinical manifestations. Plasma cell myeloma,

also known as multiple myeloma, is a malignant disorder of mature, antibody-secreting B lymphocytes, called plasma cells. Malignant plasma cells have a predilection to invade bone and form multiple tumor sites.

FIG 11.9 Peripheral blood smear showing typical cells of acute lym- phocytic leukemia. (From Onciu M: Acute lymphoblastic leukemia. Hematol Oncol Clin North Am 2009;23(4):655–674.)

FIG 11.8 Bone marrow aspirate showing small lymphocytes with condensed nuclear chromatin typical of chronic lymphocytic leukemia, B-cell type. (From Henderson ES et al, editors: Leukemia, ed 7, Phila- delphia, 2003, Saunders, color plate 11-28.)

TABLE 11.2 Comparison of Acute Lymphocytic (ALL) and Acute Nonlymphocytic Leukemia (ANLL)

ALL ANLL

Age Common in children Common in adults Hematology

results Anemia, neutropenia,

thrombocytopenia Anemia, neutropenia,

thrombocytopenia Cell morphology Small to medium

lymphoblasts, fine chromatin, indistinct nucleoli

Medium to large myeloblasts, distinct nucleoli, clear chromatin, Auer rods

Cytochemistry PAS positive, peroxidase negative, Sudan black B negative

PAS negative, peroxidase positive, Sudan black B positive

Adopted from McKenzie S: Clinical laboratory hematology, Upper Saddle River, NJ, 2004, Pearson, p 487. PAS, Periodic acid–Schiff reaction.

the result of malignant transformation of B cells (80%), with the remainder involving T cells. The abnormal cells resemble immature lymphocytes, called lymphoblasts (Fig. 11.9). Most lymphoblastic neoplasms present as leukemias, but lymphoblastic lymphomas are thought to be the same disease at a different stage. B-cell leukemias are categorized into cytogenetic groups based on common chromosomal translocations. One of these transformations results in the bcr/abl fusion gene discussed previously in the context of CML. Three other types of translocations also form fusion genes that produce abnormal signaling components. These gene derangements have different prognoses and may respond differently to alternative treatment protocols.

Lymphoblasts do not mature and accumulate in large numbers in the blood and bone marrow. At least 20% of the bone marrow cells must be leukemic lymphoblasts to meet the diagnostic criteria for ALL. The space occupied by the accumulation of leukemic cells in the bone marrow prohibits the production of normal red blood cells, platelets, and leukocytes. Circulating blasts are poorly functioning cells and do not provide effective immunocompetence (see Table 11.2 for a com- parison of ALL and acute nonlymphocytic leukemia [ANLL]).

ALL primarily affects children. It is the most common malignancy and the second-leading cause of death in this population. The peak

CHAPTER 11 Malignant Disorders of White Blood Cells 225

urine. When found in urine, these light-chain fragments are called Bence Jones protein. In addition to helping confirm the diagnosis, Bence Jones protein is important to the pathogenesis of plasma cell myeloma because it can accumulate in the kidneys and cause kidney damage. Malignant plasma cells tend to accumulate in bone, where they enhance osteoclastic activity and produce bone lesions. Pathologic fractures, especially compression fractures of the vertebral column, are common. Bone destruction releases calcium into the bloodstream, with resultant hypercalcemia.

Most of the clinical manifestations of multiple myeloma are due to bone and renal damage. The diagnosis of plasma cell myeloma is suspected based on the monoclonal antibody peak, the presence of Bence Jones protein, hypercalcemia, and evidence of bone lesions. The diagnosis is confirmed by bone marrow biopsy. Normally, the plasma cell component of the marrow comprises about 5%. In multiple myeloma, plasma cells may occupy 30% to 95% of the bone marrow (Fig. 11.12). A minimum of at least 10% to 15% of bone marrow plasma cells is necessary for the diagnosis of plasma cell myeloma. The likelihood of bone marrow dysfunction increases as the plasma cell component increases. Normal production of erythrocytes, platelets, and leukocytes can be impaired to varying degrees.

The onset of plasma cell myeloma is generally slow and insidious. A premalignant stage is apparent in some individuals who have excess production of monoclonal antibodies but no evidence of bone lesions or Bence Jones protein in the urine. This stage is called monoclonal gammopathy of undetermined significance (MGUS). Approximately 25% of patients with MGUS progress to malignant disease. Affected individuals remain asymptomatic until the disease is fairly advanced. The asymp- tomatic stage often lasts for many years after malignant transformation. During this time the only complaint may be frequent infections. Diagnosis during the asymptomatic phase is usually made because protein in the urine or high serum calcium levels are found on routine examination. Bone pain is usually the first symptom. Sometimes the evaluation of a fracture or back pain leads to the identification of myeloma. Anemia, recurrent infections, and bleeding tendencies are suggestive of bone marrow depression.

Other tissues may be targeted also, including lymph nodes, liver, spleen, and kidneys. Plasma cell myeloma occurs exclusively in the adult popula- tion, usually affecting individuals older than 40 years, with a median age at presentation of 65 years. Men are affected more often than women.

As with other forms of neoplasia, the exact etiologic process of plasma cell myeloma is unknown, but abnormalities in chromosome structure and number are commonly found. The malignant plasma cells all belong to a single clone, and the excessive antibodies they produce are identical monoclonal antibodies. These accumulate in the bloodstream and can be detected by serum protein electrophoresis. Normally, serum antibodies are of many forms (polyclonal) and show a varied distribution of size on the electrophoresis test. In plasma cell myeloma, there is a large amount of one type of antibody, which forms a characteristic spike (Fig. 11.11). Excessive production of light-chain antibody fragments by malignant plasma cells results in their accumulation in blood and

FIG 11.10 Peripheral blood smear showing cells typical of hairy cell leukemia. (From Skarin AT: Atlas of diagnostic oncology, ed 4, Philadelphia, 2010, Saunders.)

α2α1alb γβ

B

α2α1alb γβ

A

FIG 11.11 Serum protein electrophoresis comparing abnormal myeloma protein in the γ region typical of benign monoclonal gammopathy (A) with the large quantity of monoclonal antibody (spike) γ typical of plasma cell myeloma (B). (From Skarin AT: Atlas of diagnostic oncology, London, 2003, Gower Medical, pp 536–537.)

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after initiation of therapy. High-dose chemotherapy followed by allogeneic bone marrow transplantation is becoming more common and offers a better CR rate. However, the death rate associated with transplantation is high (approximately 40% to 50%). Autologous stem cell transplantation is considered to be the optimal initial therapy for most patients. Pharmacologic management of renal dysfunction is often necessary.

Chronic bone pain is a common problem in the myeloma patient that may require use of multiple remedies. Narcotic and nonnarcotic pain relievers are often necessary. Localized application of radiation to bone lesions may reduce bone pain in some cases.

Renal insufficiency is a complication experienced by approximately 50% of patients with plasma cell myeloma. Impairment of renal function is due to a combination of factors, including hyperproteinemia, high levels of Bence Jones protein, hypercalcemia, and hyperuricemia. Renal function may continue to decline over time, culminating in end-stage renal disease (chronic renal failure).

Bone involvement is a consistent feature of plasma cell myeloma. Radiologic studies of ribs, spine, skull, and pelvis show a characteristic “honeycomb” appearance, attributable to lucid areas of demineralized bone (Fig. 11.13). Minimal trauma is likely to result in fractures. Sometimes fractures occur with no known trauma; these are called pathologic fractures.

Prognosis and treatment. Antineoplastic agents may be used to induce and maintain a remission in plasma cell proliferation. The best chemotherapy regimen has not yet been determined. The remission induction rate is about 60%, with a median survival of about 3 years

FIG 11.12 Bone marrow aspirate from a patient with multiple myeloma showing a large number of abnormal plasma cells with multiple nuclei and cytoplasmic droplets. (From Kocjan G: Diagnostic cytopathology essentials. Churchill Livingstone, 2013, Elsevier.)

A B

FIG 11.13 Vertebral body (A) and skull (B) radiographs showing the characteristic “honeycomb” appearance of demineralized bone associated with multiple myeloma. (Courtesy Marvin J. Stone, MD, Sammons Cancer Center, Baylor University Medical Center, Dallas, TX.)

KEY POINTS • Chronic lymphoid leukemia (CLL) is a neoplastic transformation of a mature,

peripheral B cell that affects adults primarily and has an insidious onset. CLL is usually asymptomatic. Disease in certain genotypes is associated with long survival times and does not require therapy; in other cases, disease is progressive and may be managed with stem cell transplantation or administration of monoclonal antibodies.

• Acute lymphoid leukemia (ALL) affects children primarily, has an acute onset, responds well to therapy, and has a good prognosis. ALL is associated with transformation of precursor “blasts” in the bone marrow. ALL often manifests with bone pain, infections, and a tendency for bleeding. A significant number of children with ALL have CNS involvement, and intrathecal che- motherapy is necessary.

• Plasma cell myeloma is due to malignant transformation of antibody-secreting B lymphocytes. It primarily affects older adults. The onset of symptoms is insidious, with most patients experiencing a 4- to 10-year period of clinical latency. Some patients have a preneoplastic phase called MGUS. When present, symptoms include bone pain, pathologic fractures, anemia, thrombocytopenia, leukopenia, and renal insufficiency. Malignant plasma cells all secrete the same monoclonal antibody, and detection of this antibody in the blood or urine (Bence Jones protein) aids in diagnosis.

CHAPTER 11 Malignant Disorders of White Blood Cells 227

supraclavicular, axillary, and mediastinal nodes. Less commonly, nodes below the diaphragm are the primary site. The inguinal nodes are the most common subdiaphragmatic site. As the disease spreads from the site of origin, other lymph nodes and lymphatic tissues may become involved, including the spleen and bone marrow. Staging procedures are performed to determine the extent of metastasis at the time of diagnosis. Staging dictates the treatment modality best suited to provide the patient with the greatest chance for long-term survival.

Prognosis and treatment. The staging protocol commonly used today was first adopted in 1971 at the Ann Arbor symposium and modified later in 1989 at the Cotswold meeting (Box 11.4). The same procedure is also used for staging non-Hodgkin lymphomas. This protocol uses the presence or absence of certain clinical symptoms as well as the locations of affected nodes to determine the clinical stage of disease. The four stages are shown in Fig. 11.17. The letter A denotes

Hodgkin Disease Hodgkin disease represents about 30% of all cases of malignant lym- phoma, accounting for approximately 8500 new cases annually in the United States. It occurs across the age continuum, with half of cases occurring in persons between the ages of 20 and 40 years. The overall incidence of Hodgkin disease is higher in males, who have a worse prognosis. The overall 5-year survival rate for treated Hodgkin disease, including all stages, is about 85%.

Pathogenesis and clinical manifestations. Hodgkin disease is a malignant disorder of the lymph nodes characterized by the presence of Reed-Sternberg cells on histologic examination. Reed-Sternberg cells originate from B cells in the germinal centers of lymph nodes. Reed- Sternberg cells are malignant, but they tend to grow and spread in a predictable manner. This predictability differentiates Hodgkin disease from other types of lymphoma. Hodgkin disease usually metastasizes along contiguous lymphatic pathways (Fig. 11.14). EBV is frequently found in the genome of transformed Reed-Sternberg cells and is thought to be important in the pathogenesis of Hodgkin disease. The malignant cells are clonal, originating from a single mutant precursor cell, and usually present in a single node or localized chain of nodes. In addition to malignant Reed-Sternberg cells, inflammatory cells accumulate within the node (Fig. 11.15) such that Reed-Sternberg cells constitute only a small minority (2%) of the cells in the lymph node tumor.

There are two types of Hodgkin disease: (1) the rare lymphocyte predominance type, which accounts for 5% of cases, and (2) the classical type (cHD) representing the other 95%. The classical type can be divided further into four subtypes according to the relative number of reactive cells in the tumor. The histologic pattern does not seem to predict the prognosis. The stage of Hodgkin disease is more relevant.

Clinical manifestations of Hodgkin disease are dependent on the site of origin, as well as on the stage of dissemination. Lymphomas often are asymptomatic in the early stages. The usual clinical presentation includes painless lymphadenopathy that may be accompanied by fever, night sweats, pruritus, weight loss, and malaise. Usually enlargement occurs in lymph nodes above the diaphragm, with the cervical nodes being the most common site (Fig. 11.16). Other supradiaphragmatic nodes are the

FIG 11.14 Schematic drawing showing the orderly, contiguous, and predictable spread of Hodgkin disease. (Redrawn and modified from Rosenberg SA: Hodgkin disease: no stage beyond cure. Hosp Pract 1986;21(8):97. After original illustrations by Bunji Tagawa.)

FIG 11.15 Hodgkin/Reed-Sternberg cells. (From Vandenberghe P: Noninvasive detection of genomic imbalances in Hodgkin/Reed-Sternberg cells in early and advanced-stage Hodgkin’s lymphoma by sequencing of circulating cell-free DNA: a technical proof-of-principle study. Lancet Haematol 2015;2(2):e55–e65.)

*Clinical stage (CS) is based on history, physical examination, laboratory studies, and CT scans. Pathologic stage (PS) is based on tissue sampling obtained through invasive procedures such as laparotomy and biopsy.

Stage I Involvement of a single lymph node region or lymphoid structure (e.g., spleen, thymus, Waldeyer ring)

Stage II Involvement of two or more lymph node regions on the same side of the diaphragm. The number of anatomic regions is indicated by a subscript (e.g., II3).

Stage III Involvement of lymph node regions or structures on both sides of the diaphragm • III1: with or without splenic, hilar, celiac, or portal nodes • III2: with paraaortic, iliac, mesenteric nodes

Stage IV Involvement of extranodal site(s) beyond that designated “E” The site is indicated by a letter code followed by a plus sign (+)

Modifying Characteristics For Stages I to III E: Involvement of a single, extranodal site contiguous or proximal to known nodal site

For All Stages A: No symptoms B: Fever (temperature >38°C), drenching sweats, weight loss (>10% body weight over 6 months) X: Bulky disease • >One-third widening of mediastinum • >10 cm maximal dimension of nodal mass

BOX 11.4 Ann Arbor Staging System for Lymphomas With Cotswold Modifications*

Stage I

• Involvement of single lymph node region or • Involvement of single extralymphatic site (stage IE)

Stage II

• Involvement of 2 lymph node regions on same side of diaphragm • May include localized extralymphatic involvement on same side of diaphragm (stage IIE)

Stage III

• Involvement of lymph node regions on both sides of diaphragm • May include involvement of spleen (stage IIIS) or localized extranodal disease (stage IIIE) or both (IIIE+S)

For Hodgkin disease: III1 • Disease limited to upper abdomen—spleen, splenic hilar, celiac, or porta hepatic nodes

III2 • Disease limited to lower abdomen—periaortic, pelvic, or inguinal nodes

Stage IV

• Disseminated (multifocal) extralymphatic disease involving one or more organs (e.g., liver, bone marrow, lung, skin), with or without associated lymph node involvement or • Isolated extralymphatic disease with distant (nonregional) lymph node involvement

NOTE: Stage designation "B" indicates unexplained weight loss >10% of body weight in preceding 6 months and/or fevers of >38C and/or night sweats. Stage designation "A" indicates the absence of the features characterizing "B."

FIG 11.17 Depiction of the locations of malignant cells in the various stages of lymphoma using the Ann Arbor staging system. (From Skarin AT: Atlas of diagnostic oncology, London, 2003, Gower Medical, p 479.)

FIG 11.16 Hodgkin disease (stage IIA). Marked enlargement of cervical lymph nodes is present in this patient. It is usually painless and may be confined to only one area or may affect two or more areas. (From Skarin AT: Atlas of diagnostic oncology, London, 2003, Gower Medical, p 482.)

CHAPTER 11 Malignant Disorders of White Blood Cells 229

the absence of clinical symptoms, whereas the letter B is used when symptoms are present at the time of staging. These symptoms include loss of more than 10% of body weight, unexplained fevers, and night sweats. The clinical stage (CS) is based on history, physical examination, and noninvasive procedures such as computed tomography (CT) scan- ning. The pathologic stage (PS) is determined by the results of invasive procedures such as laparotomy and tissue biopsy. The stage dictates the treatment modalities used. In general, localized tumors are more amenable to application of radiation therapy, whereas disseminated disease responds better to systemic chemotherapeutic agents. Because Hodgkin disease often is detected while localized, radiation therapy is commonly used, with good results (Fig. 11.18).

Patients with nonbulky, stage IA or IIA disease may be candidates for radiation as sole therapy. However, a relatively high rate of relapse has been noted, and combined chemotherapy with limited-field radiation is often used. Patients with bulky disease, “B” symptoms, or stage III

and IV disease require chemotherapy with or without radiation. In early-stage disease, appropriate treatment produces a 90% 10-year disease-free survival. More aggressive chemotherapy is indicated for patients with advanced Hodgkin disease.

B-Cell, T-Cell, and NK-Cell Lymphoma (Non-Hodgkin) The malignancies included in the classification of non-Hodgkin lym- phoma are those that do not have the characteristic Reed-Sternberg cells found in Hodgkin disease. The majority of cases of non-Hodgkin lymphoma arise from lymph nodes, but they can originate in any lymphoid tissue. With the exception of a few subtypes, most cases of non-Hodgkin lymphoma occur in older adults (95%), and males are at a slightly higher risk than females. The incidence of non-Hodgkin lymphoma is on the rise, particularly in areas with large AIDS popula- tions. More than 72,000 new cases of non-Hodgkin lymphoma are diagnosed annually in the United States. The lifetime risk of developing this disease is about 1 in 50.

Most cases of non-Hodgkin lymphoma arise from B cells, T cells, or NK cells. Some of the more common types of non-Hodgkin lymphoma are summarized in Table 11.3. The prognosis and recommended treatment protocols vary according to type. A general schema for grouping non- Hodgkin lymphoma according to indolent or aggressive types is in common usage. Generally, indolent disease is associated with longer survival times, whereas aggressive lymphomas tend to be disseminated at presentation and carry a generally poorer prognosis. As a group, the non-Hodgkin types of lymphoma are more likely to spread early and unpredictably in comparison with Hodgkin disease.

Pathogenesis and clinical manifestations. The etiologic process of non-Hodgkin lymphoma is thought to be similar to that of other malignant transformations. The tumor cells are all derived from a single mutant precursor cell and are clonal. Viruses are suspected in the development of some types of lymphoma. In particular, Burkitt lym- phoma is strongly associated with the presence of EBV. Adult T-cell lymphomas are associated with infection by HTLV-1. The overall 5-year survival rate for all types of non-Hodgkin lymphomas combined is about 70%.

Most patients with non-Hodgkin lymphoma present with advanced disease (stage III or IV). Clinical manifestations may include painless lymphadenopathy, fever, night sweats, weight loss, malaise, and pruritus (similar to Hodgkin disease). A comparison of the features of Hodgkin disease and non-Hodgkin lymphoma is shown in Table 11.4. Extranodal involvement occurs early in the course of non-Hodgkin lymphoma, and patients may present with infiltrative disease of the skin, gastro- intestinal tract, bone, or bone marrow. Complications occur more frequently than in Hodgkin disease. Two of the most serious oncology emergencies are obstruction of the superior vena cava and spinal cord compression. Infection, bone metastasis, and joint effusions are also common. Staging of non-Hodgkin lymphoma is done in the same way as for Hodgkin disease, and the classification system is not different. Earlier clinical stages are associated with the best prognosis for survival.

Prognosis and treatment. The effectiveness of therapy for non- Hodgkin lymphoma is variable. Favorable outcomes are likely in stage I and II disease. However, non-Hodgkin lymphoma is likely to present as stage III or IV disease, which has a poor prognosis. Therapeutic management is determined by the clinical stage, histologic type, patient age, and bone marrow integrity at the time of diagnosis. Radiation, chemotherapy, and tissue-specific therapies such as monoclonal antibod- ies and bone marrow transplants may all be applicable.

FIG 11.18 Typical radiation fields for lymphoma. Different fields of radiation may be used depending on the location of disease.

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TABLE 11.3 Summary of Major Types of Lymphoid Leukemias and Non-Hodgkin Lymphomas

Diagnosis Cell of Origin Genotype Salient Clinical Features

Neoplasms of Immature B and T Cells B-cell acute lymphoblastic

leukemia/lymphoma* Bone marrow precursor B

cell Diverse chromosomal translocations;

t(12;21) involving RUNX1 and ETV 6 present in 25%

Predominantly children; symptoms relating to marrow replacement and pancytopenia; aggressive

T-cell acute lymphoblastic leukemia/lymphoma

Precursor T cell (often of thymic origin)

Diverse chromosomal translocations, NOTCH1mutations (50%–70%)

Predominantly adolescent males; thymic masses and variable bone marrow involvement; aggressive

Neoplasms of Mature B Cells Burkitt lymphoma* Germinal-center B cell Translocations involving MYCand lg

loci, usually t(8;14); subset EBV-associated

Adolescents or young adults with extranodal masses; uncommonly presents as “leukemia”; aggressive

Diffuse large B-cell lymphoma† Germinal-center or postgerminal center B cell

Diverse chromosomal rearrangements, most often ofBCL6 (30%), BCL2 (10%), or MYC (5%)

All ages, but most common in older adults; often appears as a rapidly growing mass; 30% extranodal; aggressive

Extranodal marginal zone lymphoma

Memory B cell t(11;18), t(1;14), and t(14;18) creating MALT1-IAP2, BCL10-IgH, and MALT1-IgH fusion genes, respectively

Arises at extranodal sites in adults with chronic inflammatory diseases; may remain localized; indolent

Follicular lymphoma† Germinal-center B cell t(14;18) creating BCL2-IgHfusion gene Older adults with generalized lymphadenopathy and marrow involvement; indolent

Hairy cell leukemia Memory B cell Activating BRAF mutations Older males with pancytopenia and splenomegaly; indolent

Mantle cell lymphoma Naive B cell t(11;14) creating CyclinD1 -IgH fusion gene

Older males with disseminated disease; moderately aggressive

Multiple myeloma/solitary plasmacytoma†

Postgerminal-center bone marrow homing plasma cell

Diverse rearrangements involving IgH; 13q deletions

Myeloma: older adults with lytic bone lesions, pathologic fractures, hypercalcemia, and renal failure; moderately aggressive Plasmacytoma: isolated plasma cell masses in bone or soft tissue; indolent

Small lymphocytic lymphoma/ chronic lymphocytic leukemia

Naive B cell or memory B cell

Trisomy 12, deletions of 11q, 13q, and 17p

Older adults with bone marrow, lymph node, spleen, and liver disease; autoimmune hemolysis and thrombocytopenia in a minority; indolent

Neoplasms of Mature T Cells or NK Cells Adult T-cell leukemia/

lymphoma Helper T cell HTLV-1 provirus present in tumor cells Adults with cutaneous lesions, marrow involvement,

and hypercalcemia; occurs mainly in Japan, West Africa, and the Caribbean; aggressive

Peripheral T-cell lymphoma, unspecified

Helper or cytotoxic T cell No specific chromosomal abnormality Mainly older adults; usually presents with lymphadenopathy; aggressive

Anaplastic large-cell lymphoma Cytotoxic T cell Rearrangements of ALK(anaplastic large cell lymphoma kinase) in a subset

Children and young adults, usually with lymph node and soft-tissue disease; aggressive

Extranodal NK/T-cell lymphoma NK-cell (common) or cytotoxic T cell (rare)

EBV-associated; no specific chromosomal abnormality

Adults with destructive extranodal masses, most commonly sinonasal; aggressive

Mycosis fungoides/Sézary syndrome

Helper T cell No specific chromosomal abnormality Adult patients with cutaneous patches, plaques, nodules, or generalized erythema; indolent

Large granular lymphocytic leukemia

Two types: cytotoxic T cell and NK cell

Point mutations in STAT3 Adult patients with splenomegaly, neutropenia, and anemia, sometimes, accompanied by autoimmune disease

EBV, Epstein-Barr virus; HIV, human immunodeficiency virus; Ig, immunoglobulin; NK, natural killer. *Most common tumors in children †Most common tumors in adults. Modified from Kumar V et al, editors: Pathologic basis of disease, ed 9, Philadelphia, 2015, Saunders, p 591.

CHAPTER 11 Malignant Disorders of White Blood Cells 231

TABLE 11.4 Clinical Differences in Hodgkin Disease and Non-Hodgkin Lymphoma

Characteristic Hodgkin Disease Non-Hodgkin Lymphoma

Pattern of spread Contiguous spread Noncontiguous spread Extranodal

disease Uncommon More common involvement

of gastrointestinal tract, testes, bone marrow

Site of disease Mediastinal involvement common

Mediastinal involvement less common

Bone marrow involvement uncommon

Bone marrow involvement common

Liver involvement uncommon

Liver involvement common

Extent of disease Often localized Rarely localized B symptoms Common Uncommon

KEY POINTS • Hodgkin disease is characterized by malignant transformation of B cells in

lymph nodes, called Reed-Sternberg cells. The spread of malignant cells occurs along predictable, contiguous pathways. Most commonly, a single cervical lymph node is involved initially, with slow progression to nearby nodes.

• Non-Hodgkin lymphoma constitutes a diverse group of malignant diseases of lymphoid tissue. The characteristic Reed-Sternberg cell of Hodgkin disease is not present. Non-Hodgkin lymphoma is unpredictable in its spread and is often disseminated at diagnosis.

• Manifestations of Hodgkin disease and non-Hodgkin lymphoma are similar. These include painless lymph node enlargement, fever, night sweats, and weight loss. Early-stage disease is often asymptomatic.

• Staging is done to determine the degree of dissemination of disease. When affected lymph nodes are localized to one area (stage I) or one side of the diaphragm (stage II), the prognosis for cure is very good. Dissemination to lymph nodes above and below the diaphragm (stage III) or to extralymphatic organs or tissues (stage IV) carries a poorer prognosis.

• Radiation of the involved field is commonly used for malignant lymphoma in early stages. More disseminated disease may be treated with chemo- therapeutic protocols. Non-Hodgkin lymphoma is routinely treated with chemotherapy because the disease is often well advanced at the time of diagnosis. Treatment may lead to bone marrow suppression and may predispose the patient to anemia, thrombocytopenia, and leukopenia.

Malignant disorders of white blood cells are classified according to cell type and fall into two major categories: myeloid neoplasms and lymphoid neoplasms. Myeloid neoplasms commonly present as leukemia and usually involve transformation of granulocytes. Lymphoid neoplasms may present as leukemia, lymphoma, or plasma cell myeloma. Leukemia is a malignant neoplasm of immature stem cells that is characterized by diffuse replacement of the bone marrow by neoplastic blasts. In most cases the leukemic cells overflow into the bloodstream, where they may be seen in large numbers. These cells may also infiltrate the liver, spleen, lymph nodes, and other tissues throughout the body. Lymphoma is characterized by malignancy of cells found in lymphoid tissues and usually arises in the lymph nodes. Hodgkin disease is a special category of malignant lymphoma that is characterized by the presence of Reed-Sternberg cells. Hodgkin disease is more predictable in its spread than the non-Hodgkin types of lymphoma, and it is generally curable

in the early stages. Non-Hodgkin lymphoma types comprise a large number of different disorders that involve malignant transformation of B cells, T cells, or NK cells. As with Hodgkin disease, earlier stages are more easily cured. However, the non-Hodgkin lymphomas tend to be unpredictable in their dissemination, and the prognosis is less certain. Plasma cell myeloma is a malignant transformation of mature, antibody-secreting B cells. Malignant plasma cells are monoclonal, and all produce identical antibodies, which accumulate in the blood. These cells have a predilection to settle in skeletal structures, where they cause bone demineralization and destruction. Hypercalcemia, bone fractures (pathologic fractures), and renal damage are common complications of plasma cell myeloma. Treatment for the various types of hematologic neoplasms continues to evolve, and excellent disease-free survival is commonly achieved when the disease is diagnosed in the early stages.

S U M M A R Y

RESOURCES Etiology and Classification of Hematologic Neoplasms Henderson ES, Lister TA, Greaves MF, editors: Leukemia, ed 7, Philadelphia,

2002, Saunders. Jaffe ES, Harris NL, Stein H, Vardiman JW, editors: Pathology and genetics of

tumours of haematopoietic and lymphoid tissues, Lyon, France, 2001, IARC Press.

Lowenberg B, Griffin JD, Tallman MS: Acute myeloid leukemia and acute promyelocytic leukemia. Hematology 82–101, 2003. doi:10.1182/ asheducation-2003.1.82.

McKenzie SB, Williams L: Clinical laboratory hematology, Upper Saddle River, NJ, 2015, Pearson Education, 3/E.

National Cancer Institute: https://seer.cancer.gov/statfacts/. Ross JA, Potter JD, Reaman GH, et al: Maternal exposure to potential

inhibitors of DNA topoisomerase II and infant leukemia (United States):

a report from the Children’s Cancer Group. Cancer Causes Control 7(6):581–590, 1996.

Tessoulin B, Eveillard M, Lok A, et al: p53 dysregulation in B-cell malignancies: More than a single gene in the pathway to hell. Blood Rev, 2017. S0268-960X(16)30059-5. doi: 10.1016/j.blre.2017.03.001.

Myeloid Neoplasms American Cancer Society: Cancer facts and figures, 2015, Atlanta, GA, 2003,

Author. Aster JC: The hematopoetic and lymphoid systems. In Kumar V, Abbas AK,

Fausto N, Mitchell R, editors: Robbins basic pathology, ed 8, Philadelphia, 2007, Saunders, pp 421–478.

Barille-Nion S, et al: Advances in biology and therapy of multiple myeloma. Hematology 248–278, 2003. doi:10.1182/asheducation-2003.1.248.

Henderson ES, Lister TA, Greaves MF, editors: Leukemia, ed 7, Philadelphia, 2002, Saunders.

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Hoffbrand AV, Moss PAH: The World Health Organization (WHO) classification of the tumors of haematopoietic and lymphoid tissues. In Essential haematology, ed 6, Oxford, England, 2011, Blackwell.

Keating MJ, et al: Biology and treatment of chronic lymphocytic leukemia. Hematology 153–175, 2003. doi:10.1182/asheducation-2003.1.153.

Linker CA: Blood. In Tierney LM, McPhee SJ, Papadakis MA, editors: Current medical diagnosis and treatment, ed 46, New York, 2007, McGraw-Hill, pp 493–547.

McKenzie SB, Williams L: Clinical laboratory hematology, Upper Saddle River, NJ, 2015, Pearson Education. 3/E,.

Melo JV, Hughes TP, Apperley JF: Chronic myeloid leukemia. Hematology 132–152, 2003. doi:10.1182/asheducation-2003.1.132.

Spivak JL, et al: Chronic myeloproliferative disorders. Hematology 200–224, 2003. doi:10.1182/asheducation-2003.1.200.

Lymphoid Neoplasms Carbone PP, Kaplan HS, Musshoff K, et al: Report of the Committee on

Hodgkin’s Disease Staging Classification. Cancer Res 31:1860–1861, 1971.

Diehl V, Stein H, Hummel M, et al: Hodgkin’s lymphoma: biology and treatment strategies for primary, refractory and relapsed disease. Hematology 225–247, 2003. doi:10.1182/asheducation-2003.1.225.

Iacobucci I, Mullighan CG: Genetic Basis of Acute Lymphoblastic Leukemia. J Clin Oncol 35(9):975–983, 2017.

Lister TA, et al: Report of a committee convened to discuss the evaluation and staging of patients with Hodgkin’s disease: Cotswolds Meeting. J Clin Oncol 7(11):1630–1636, 1989.

Rytting ME, Jabbour EJ, O’Brien SM, Kantarjian HM: Acute lymphoblastic leukemia in adolescents and young adults. Cancer 2017. doi:10.1002/ cncr.30624.

Vose JM, Chiu BCH, Cheson BD, et al: Update on epidemiology and therapeutics for non-Hodgkin’s lymphoma. Hematology 241–262, 2002. doi:10.1182/asheducation-2002.1.241.

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12

HIV Disease and AIDS Faith Young Peterson

K E Y Q U E S T I O N S • What are the common modes of HIV transmission, and how can

infection be prevented? • What is the scope of the HIV/AIDS epidemic in the United States

and the world? • How does infection with HIV lead to progressive

immunodeficiency and AIDS? • How has knowledge of the HIV life cycle led to the development

of multidrug treatment strategies?

• How are CD4+ cell counts and various clinical findings used to classify the stages of HIV disease and AIDS?

• What are the common systemic manifestations of AIDS and associated opportunistic infections?

• What are the current treatment recommendations for HIV disease and AIDS?

C H A P T E R O U T L I N E Epidemiology, 234

History, 234

Types of HIV, 234

Transmission, 236

Prevention of Transmission, 238

Etiology, 239 HIV Structure, 239

HIV Binding and Infection, 239

Pathogenesis, 242 Effect of HIV on Immune Cells at the Cellular Level, 242

Viral Production and Cell Death, 242

Progression of HIV Infection from Seroconversion to AIDS, 244

CDC HIV Classification System, 245

Diagnostic Testing, 245 Monitoring the Progression of HIV, 246 Clinical Manifestations, 248

Systemic Manifestations, 248

Gastrointestinal Manifestations, 249

Pulmonary Manifestations, 249

Mucocutaneous Manifestations, 250

Gynecologic Manifestations, 251

Neurologic Manifestations, 252

Ocular Manifestations, 253

Cardiovascular Manifestations, 253

Manifestations in Other Systems, 253

Manifestations in Children, 254

Treatment, 254 Antiretroviral Therapy Recommendations, 254

Nucleoside Reverse Transcriptase Inhibitors, 255

Nucleotide Reverse Transcriptase Inhibitors, 255

Nonnucleoside Reverse Transcriptase Inhibitors, 255

Protease Inhibitors, 257

Fusion Inhibitors, 257

CCR5 Inhibitors, 257

Integrase Strand Transfer Inhibitors, 257

Other Treatments and Vaccines, 257

http://evolve.elsevier.com/Banasik/pathophysiology/

This chapter focuses on HIV disease and AIDS—from epidemiology to pathogenesis and management. Human immunodeficiency virus (HIV) is the prototypical public health infectious disease of the late twentieth century. It does not act like other infectious organisms that overwhelm the immune system. Although originally thought to be a rapid killer, it is a long-term, complex, chronic disease caused by persistent replication of HIV that leads to immunodeficiency. It triggers chronic widespread and diverse organ involvement with varying signs and

symptoms. It encompasses all the armamentarium of a viral infection that has completed the evolutionary progression from animal to human. HIV has done more than just confuse and captivate scientists and health professionals; it also has mobilized risk groups and placed medicine and society at a crossroads of opinion. In this epidemic, the lines between privacy and public health and between morality and compassion have been debated. HIV disease is complex. However, in its complexity, it has opened the door to better understanding of the immune system.

• Review Questions and Answers • Glossary (with audio pronunciations for selected terms) • Animations

• Case Studies • Key Points Review

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The rate of persons living with an HIV/AIDS diagnosis also varies by geographic region. The Northeast and South report the highest numbers of HIV/AIDS diagnoses, particularly in urban areas. For example, the South reported 45% of new AIDS diagnoses followed by 24% in the Northeast, 19% in the West, and 13% in the Midwest. The highest rates of new diagnoses of HIV are in African American men and women in all geographic regions except in the West.

Approximately 20% of new HIV infections occur in women, and 23% of those living with HIV are women. HIV infections in women are usually due to heterosexual contact (84%) or injection drug use (16%). It is thought that noninjection drugs (such as crack cocaine or methamphetamine) may also contribute to the spread of HIV/AIDS because of sex trading for drugs, shelter, or money. African American and Hispanic women account for 80% of all HIV diagnoses in women in the United States.

People living with HIV older than age 50 comprise 20% of all HIV infections in the United States. Initial infection in this age group is often as a result of a decreased perception of risk. Despite improved diagnoses and treatment, people older than 50 comprise 50% of HIV deaths. In the 50 to 54 age group, HIV is one of the top causes of death in the United States.

History In 1981 the first descriptions of immunodeficiency disease in previously healthy persons appeared in the medical literature. At that time, previously healthy young homosexual men contracted unusual diseases for their age group in increasing numbers, such as Pneumocystis jiroveci (carinii) pneumonia (PCP) and Kaposi sarcoma, that researchers identified as HIV. The first evidence of alternative forms of transmission of the virus by blood and blood products appeared in 1982. All these early patients were shown to have a type of HIV virus called HIV-1. It was at this time that the term acquired immunodeficiency syndrome (AIDS) was first used. However, the specific retrovirus causing HIV infection and AIDS was not isolated until the early to mid-1980s. The timeline of HIV history is found in Table 12.2.

Types of HIV HIV is a type of retrovirus from the subfamily Lentivirinae, with Lentivirus being its only genus. This subfamily is so named from the Latin word lentus, meaning “slow,” because infection develops gradually. HIV-2, a related but distinct retrovirus, was later identified in 1986 and is most closely related to simian immunodeficiency virus. HIV-2 is differentiated from HIV-1 by a longer clinical latency period from the onset of infection to the development of symptoms. It is also characterized by having lower plasma HIV-2 RNA viral loads and lower mortality rates. HIV-2 infection can progress to AIDS, even though it appears to be less virulent than HIV-1. It is also possible to be coinfected with both HIV-1 and HIV-2.

HIV-1 and HIV-2 are found worldwide. They are similar in structure and function, but are differentiated from each other by their envelope glycoproteins, point of origin, and latency periods. The point of origin for HIV-1 is Central Africa, and for HIV-2 it is West Africa. HIV-1 is the causative organism of most cases found in Central Africa, the United States, Europe, and Australia. HIV-2 is found primarily in West Africa or in countries with strong socioeconomic ties to West Africa (e.g., France, Spain, Portugal, and former Portuguese colonies).

Many subspecies or strains of HIV also exist because of the rapid rate of HIV virion mutation. The subspecies may exist in different hosts, as well as within an individual host. Currently, at least 10 subtypes of HIV-1 have been identified: group N (YBF30), group O, and group M with 8 subtypes (A, B, C, D, E, F, G, and H). Research is currently focusing on the identification of HIV subtypes and strains in different

Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are acquired immunodeficiency disorders resulting in defective cell-mediated immunity, especially the decrease in CD4+ or T helper/inducer lymphocytes. CD4+ T cells are necessary for appropriate immune responsiveness because they are the cells that mediate between the antigen-presenting cells and other immune cells, such as B cells and other T cells. CD4+ lymphocytes are characterized by the presence of the CD4 receptor.

EPIDEMIOLOGY HIV infection is a primary immunodeficiency disease caused by the retroviruses HIV type 1 and HIV type 2. Despite research and public health surveillance and prevention activities, the virus has continued mutating and spreading globally. HIV infects people worldwide. Since its identification in the early 1980s, the HIV global epidemic continues with an estimated 36.9 million people living with HIV worldwide as of 2014 and a total of 1.2 million AIDS deaths worldwide in 2014. The number of adults living with HIV is estimated to be 34.3 million. Of those, 17.4 million people are women. There are also 2.6 million children (<15 years) estimated to be living with HIV globally. AIDS-related deaths worldwide have fallen by 42% since 2004. Selected aspects of the global impact of HIV and AIDS are illustrated in Table 12.1.

According to the World Health Organization (WHO), the number of new HIV infections globally declined 35% since 2000, attributable to expanded and improved HIV programs. There were approximately 2 million people estimated to be newly infected with the HIV virus in 2014. New HIV infections in children have decreased 58% since 2000 with 220,000 children newly infected with HIV and 150,000 deaths in children in 2014. Of the newly infected people with HIV, 15 countries account for more than 75%. These 15 countries include Brazil, Cameroon, China, India, Indonesia, Kenya, Mozambique, Nigeria, Russian Federation, South Africa, Uganda, United Republic of Tanzania, United States of America, Zambia, and Zimbabwe. HIV infection rates are influenced by location and population and as such continue to increase in sub- Saharan Africa, which has the highest number of people living with HIV (24.8 million), as well as in Eastern Europe (1.5 million) and central Asia (5.0 million). In those countries, people infected with HIV have more limited access to testing and medication for treatment, as well as limited information for prevention because of the effects of gender inequity and harmful social norms that drive transmission.

In the United States it is estimated by the Centers for Disease Control and Prevention (CDC) that there are more than 1.2 million persons living with HIV/AIDS in the United States, with 47,352 people newly diagnosed with HIV infections in 2013. In the United States and other industrialized countries where access to medication, care, and prevention is greater, the number of patients diagnosed with and dying from AIDS is stable or declining (Fig. 12.1). In 2013 26,688 people were diagnosed with AIDS. However, the CDC estimates that approximately 12.8% of the people who are infected with HIV in the United States may be unaware that they are infected. Since 1981, 658,507 people with AIDS in the United States have died.

Current statistics show that of the people diagnosed with HIV/AIDS in the United States, men who have sex with men (MSM), injection drug users, racial and ethnic minorities, and women of color are dis- proportionately affected. Among racial and ethnic groups, 41% of people living with HIV infection and most of the new cases are African Americans, especially those in the youngest age group. Hispanics account for approximately 20% of people living with HIV infection and 21% of new HIV infections. According to the CDC, 63% of new HIV infections occur in MSM. New HIV infections occur in approximately 8% of injection drug users, who represent 15% of those living with HIV.

CHAPTER 12 HIV Disease and AIDS 235

TABLE 12.1 Global Health Considerations for HIV/AIDS

Country/ Region

Prevalence of Disease Cultural Factors

Most Common Means of Transmission Treatment

Economic/Social Impact

Sub-Saharan Africa

25.8 million people affected. This region carries most of the world’s HIV/AIDS burden. Nigeria, South Africa and Uganda account for 48% of all new HIV infections. Adult prevalence % = 4.8%

Adult and child deaths due to AIDS = 790,000

Gender inequalities: Males dominate sexual decision making and adolescent girls and young women are disproportionately infected.

Heterosexual sex and mother-to-child transmission

Treatment is available but it depends on the country. Treatment coverage = 90% of those who test positive for HIV. 76% of people on HAART achieve viral suppression. However, Central African Republic, Democratic Republic of the Congo, Nigeria and South Sudan have high HIV burden, low treatment coverage, and no or little decline in new HIV infections.

Life expectancy depends on access to treatment. Untreated populations have decreased life expectancy. Stigma associated with disease causes people to lose property.

Middle East and North Africa

240,000 people affected. Adult prevalence % = 0.1%. Adult and child deaths due to AIDS = 12,000

Gender inequalities: Males dominate sexual decision making. Marked stigma.

Heterosexual sex and mother-to-child transmission

Only 11% of infected people are receiving antiretroviral therapy New infections have risen by 7%. AIDS-related deaths have risen by 66% since 2005.

Asia/Pacific 5.0 million people affected.

Adult prevalence % = 0.2%. Adult and child deaths due to AIDS = 240,000

Growing male demographic has led to a growing sex industry.

Intravenous drug use, prostitution, and transmission through migrant workers

Medical coverage in rural areas is poor, so a large proportion of the population must pay out of pocket. Treatment coverage: 31%

Cost of therapy generally exceeds annual income. Stigma is so great that many people do not disclose their HIV status to their families and thus do not seek treatment.

Western and Central Europe and North America

2.4 million people affected. Adult prevalence % = 0.3%. Adult and child deaths due to AIDS = 26,000.

Continued stigma Men having sex with men (MSM), intravenous drug use, heterosexual transmission, and prostitution

Treatment available to most people. The percentage of people receiving treatment is highest at 51%.

New infections have risen by 8% by 2005.

Cost of therapy is high but programs are available for assistance

Eastern Europe and Central Asia

1.5 million people affected. Adult prevalence % = 0.9%. Adult and child deaths due to AIDS = 62,000

Continued stigma MSM, intravenous drug use, heterosexual transmission and prostitution

Treatment availability varies. Russian Federation has low treatment coverage and no or little decline in new HIV infections. New infections have risen by 5% since 2005.

AIDS-related deaths have risen by 5% since 2005.

Caribbean 280,000 people affected. Adult prevalence % = 1.1%. Adult and child deaths due to AIDS = 8,800

Continued stigma MSM, intravenous drug use, heterosexual transmission, and prostitution

New infections declined most = 40% since 2005

Latin America 1.7 million people affected. Adult prevalence % = 0.4%. Adult and child deaths due to AIDS = 41,000

MSM are highly stigmatized, so prevention efforts overlook this group. Drug use is commonplace

MSM, intravenous drug use, and prostitution

45% of infected people are receiving antiretroviral therapy. The government provides therapy for free.

Government has had a strong and positive response to the epidemic: its efforts have reduced stigma, improved social reintegration, and reduced HIV prevalence among high-risk populations.

UNAIDS Press Release. UNAIDS report shows that 19 million of the 35 million people living with HIV today do not know that they have the virus. Geneva, July 16, 2014.

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concomitant sexually transmitted diseases or genital lesions increase the risk of HIV infection. In women, high-risk heterosexual contact is influenced by lack of HIV knowledge, low socioeconomic status, low perception of risk, concomitant drug or alcohol use, relationship dynamics such as fear of abuse or loss of relationship, and the increased biological vulnerability of HIV contraction during vaginal intercourse, especially in the presence of other sexually transmitted diseases or vaginal inflammation. In both men and women, the use of noninjection drugs (such as crack cocaine) contributes to HIV transmission by decreasing inhibition, allowing the person to engage in risky sexual behaviors or to trade sexual relations for drugs or money.

Blood bank screening and testing procedures have nearly eliminated the transmission of HIV-contaminated blood in the United States. In the United States all blood and blood products have been tested by HIV-1, HIV-2, and HIV-1 p24 antigen tests since 1996. However, this route of transmission continues in third-world countries, where there is a high number of HIV-infected persons and much of the blood and blood products are not screened before use.

Health care workers who are exposed to blood or infected body fluids or needles/sharp instruments are at risk of contracting HIV. The risk of developing HIV is greatest for those health care workers who have a deep injury with visible blood from a contaminated needle or sharp instrument or who have a direct puncture into an artery or vein. They also are at risk if they have prolonged blood–skin contact, especially if extensive. The risk of infection is much lower when both universal precautions and postexposure prophylaxis are employed.

Transmission from an infected mother to her infant may occur in the intrauterine period, in the intrapartum period at the time of delivery, or in the postpartum period via breast feeding; it may also be transmitted in some cultures from saliva attributable to premastication. Of these, intrapartum transmission at the time of delivery is thought to be the most common. HIV infection does not cause any specific congenital abnormalities, but there is an increased risk of spontaneous

populations and geographic areas. For example, in the United States, Europe, and Australia, most infected persons have HIV-1, subtype B, whereas in India, HIV-2 is found near Goa, and HIV-1 strains A, B, and C are also present.

Transmission HIV-1 and HIV-2 are relatively weak viruses outside of the body. HIV viruses can infect people through three major types of transmission: sexual transmission via semen or vaginal and cervical secretions through homosexual, bisexual, or heterosexual intercourse; parenteral transmission via blood, blood products, or blood-contaminated needles or syringes; and perinatal transmission in utero, during delivery, or in breast milk. Of these forms of transmission, sexual transmission through unprotected vaginal or anal intercourse is the most common mode of infection globally. HIV is found in every bodily fluid and is broadly disseminated in the body. In very low titers, HIV is known to be present but has not been shown to be transmitted via urine, saliva, tears, cerebrospinal fluid, amniotic fluid, and feces. HIV is not known to be transmitted via aerosol routes. In the United States those at greatest risk of HIV infection include (1) MSM; (2) intravenous drug users (IVDs) who share needles or syringes; (3) sexual partners of those in high-risk groups, particularly heterosexual women; and (4) infants born to infected mothers. Heterosexual intercourse with infected partners, contact with contaminated blood, and prenatal or perinatal exposure of the infant are the major routes of transmission of HIV in Africa, South and Southeast Asia, and developing countries. In these countries, an equal proportion of males and females are infected.

Common modes of transmission include needle/syringe sharing between IVDs, unprotected sex with infected partners, recipients of HIV-contaminated blood or blood products or infected semen during artificial insemination, unanticipated needle or scalpel injury during care or surgical treatment of infected patients, and neonatal transmission from an infected mother to her infant. In both men and women,

Classifications

Year of classification

Note. Deaths of persons with HIV infection, stage 3 (AIDS) may be due to any cause.

Stage 3 (AIDS) Classifications, Deaths, and Persons Living with Diagnosed HIV Infection Ever Classified as Stage 3 (AIDS) 1985–2014–United States and 6

Dependent Areas C

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Prevalence

1985 1986

1987 1988

1989 1990

1991 1992

1993 1994

1995 1996

1997 1998

1999 2000

2001 2002

2003 2004

2005 2006

2007 2008

2009 2010

2011 2013

2014 2012

90

80

70

60

50

40

30

20

10

0

600

500

400

300

200

100

0

FIG 12.1 Estimated AIDS incidence and deaths among persons with AIDS, by year of diagnosis or death and year-end prevalence, United States, 1985 to 2014. Data were adjusted for delays in reporting of cases and deaths. (From Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/library/slideSets/ index.html.)

CHAPTER 12 HIV Disease and AIDS 237

of HIV perinatal transmission is reduced with the use of antiretroviral therapy during pregnancy and during the first months of the infant’s life.

Routine social contact with people who are HIV positive does not increase one’s risk of HIV infection. The following examples are safe practices and will not cause exposure to HIV infection: using public restrooms, swimming in public swimming pools, touching or hugging someone who is HIV positive, and eating with community utensils or in restaurants. Insects such as mosquitoes cannot transmit the HIV virus to humans.

abortion. The overall risk to the fetus of HIV transmission is estimated to be between 15% and 40% for each pregnancy, with increasing risk in subsequent pregnancies for each HIV-positive fetus born. Increased risks of antepartum transmission include increased maternal viral load or high viremia during early infection, advanced maternal clinical disease as evidenced by low CD4+ counts, and breaks in the placental barrier. Increased risks of intrapartum transmission include high maternal viral load at the time of delivery, prolonged ruptured membranes (more than 4 hours), infant exposure to blood/secretions, abruptio placentae, infant prematurity, and the presence of coinfections. The rate

TABLE 12.2 HIV History Timeline Synopsis 1900 Retroviruses identified as cause of cancer in chickens 1930s HIV-1 precursor virus crossed species from chimpanzees to humans during hunting from contact with infected chimpanzee blood 1950s Positive tests on serum from man in Leopoldville (now Kinshasa) Congo 1960s Virus reaches Haiti 1968 First case in United States in sexually active 15-year-old African American male in St. Louis 1980 First retrovirus identified in humans affecting T cells (human T-cell lymphocytic virus, HTLV-1) 1981 Syndrome of HIV first reported in healthy young homosexual men in Los Angeles and New York. First clinical article in MMWR. 1982 Identification of HIV transmission by blood/blood products with first use of term AIDS. Syndrome also identified in women, infants, Haitians,

and persons who had received blood or blood products 1983 CDC publishes first Blood and Body Fluid Precautions.

First WHO meeting on AIDS. 1985 First HIV-1 antibody testing (ELISA and Western Blot).

First international conference on AIDS 1987 HIV-2 identified in visitor to United States from West Africa.

First anti-HIV drug approved. CDC revises guidelines with identification of mucocutaneous exposure – “Universal Blood and Body Fluid Precautions.”

1988 World Health Organization (WHO) declares December 1 as World AIDS Day. 1989 FDA approves aerosolized pentamidine for PCP prophylaxis.

Second federal commission on AIDS established. 1990 Ryan White Comprehensive AIDS Resources Emergency Act signed into law. 1991 Earvin (Magic) Johnson announces his HIV-positive status.

OSHA mandates Universal Precautions. 1992 FDA approves the use of AZT and zalcitabine (ddC, Hivid) for concurrent treatment of HIV infection. 1993 Scientists reveal AZT-resistant HIV strains are being transmitted to newly infected individuals. 1994 CDC announces that AIDS is leading cause of death among Americans 25–44 years old 1995 FDA approves the first protease inhibitor (saquinavir).

Establishment of the Presidential Advisory Council of HIV/AIDS. U.S. PHS recommends that pregnant women be offered AZT to reduce the possibility of perinatal transmission.

1996 Combination antiretroviral therapy (HAART) is introduced. 1997 CDC warns that the number of AIDS cases among people over age 50 is slowly increasing. 1999 Researchers discover origins of HIV-1 from chimpanzee species (see 1930s).

Behavioral studies report recidivism in regard to safer sex practices among MSM in both Europe and the United States. 2006 WHO declares March 8 as National Women’s & Girls HIV/AIDS Awareness Day.

SMART trial found that episodic antiretroviral therapy more than doubles risk of AIDS or death in people with HIV infection 2014 Worldwide, HIV/AIDS is the leading cause of death for women in their reproductive years.

WHO report indicates that 19 million of the 35 million people living with HIV do not know their HIV status. 2015 WHO issues new guidelines for treatment of all HIV-infected persons at the time of diagnosis regardless of CD4+ T cell count.

Compiled from the following sources: Balter M: Virus from 1959 sample marks early years of HIV, Science 279:801, 1998. Garry RF et al: Documentation of an AIDS virus infection in the United States in 1968, JAMA 260(14):2085-2087, 1988. Lemey P et al: Tracing the origin and history of the HIV-2 epidemic, Proc Natl Acad Sci USA 10.1073/pnas.0936469100, 2003. Ungvarski PJ: The past 20 years of AIDS. AJN, 101(6):26-29, June, 2001. Varmus H: Retroviruses. Science 240:1427-1435. UNAIDS: Press Release: UNAIDS report shows that 19 million of the 25 million people living with HIV today do not know that they have the virus and Core Epidemiology Slides, Geneva, July 16, 2014, World Health Organization (WHO). Division of HIV/AIDS Prevention: HIV in the United States: At a Glance, Atlanta, GA, July, 2014, Centers for Disease Control and Prevention (CDC). Division of HIV/AIDS Prevention: HIV and AIDS in the United States by Geographic Distribution, Atlanta, GA, May 11, 2015, Centers for Disease Control and Prevention (CDC).

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use. When using bleach, the user must rinse out all blood first; then fill the needle and syringe with full-strength bleach at least three times for 30 to 60 seconds.

Medical and health care personnel are at risk through occupational exposure to blood and body fluids. The degree of occupational risk varies with the type and severity of exposure. For example, the average risk for HIV transmission after a needle-stick exposure to HIV-infected blood is estimated to be approximately 0.3%. Self-protection through the use of standard precautions can decrease risk by reducing exposure. Health care providers should carefully wash their hands before and immediately after patient contact even when using gloves. It is essential to wear disposable gloves for any actual or potential contact with blood or body secretions, when handling items contaminated with blood or body fluids, when performing finger sticks or heel sticks, or when the health care provider has scratches or cuts on the hand.

Gowns or plastic aprons, masks, goggles, or face shields should be worn to protect the face and clothing when there is risk of splashes and airborne droplets of blood or body fluids. Protective gear should be changed between patients. Careful prevention of parenteral exposure when using needles or other equipment should be emphasized. Needles and sharp implements should be disposed in rigid, puncture-proof containers. Such implements should not be bent, broken, or recapped before disposal. In combative patients who must have blood drawn or injections given, careful use of humane and limited restraint devices may be necessary to prevent injury to the involved health care workers. Resuscitation bags and masks should be readily available to minimize the need for mouth-to-mouth procedures.

Unfortunately, accidents necessitating the development of postexpo- sure prevention protocols do occur. If a health care worker sustains an injury with significant exposure to blood or body fluids such as a needle stick and the source patient is HIV positive, prophylaxis should be given immediately after a workplace postexposure prevention protocol. If the source patient tests negative, if there is concern about new infection, or if the HIV status is unknown, the health care worker should be offered prophylaxis. The selection of a drug regimen for HIV postexposure prophylaxis must balance the risk for infection against potential toxicities and side effects of the medication(s). The postexposure protocol usually involves the administration of three medications—emtricitabine/tenofovir (Truvada) and raltegravir (Isentress)—for 4 weeks. This combination of medications is usually well tolerated and has fewer drug interactions. The length of administration of the agents depends on multiple factors and may be longer. This same protocol has been advocated for use as postsexual exposure prophylaxis.

Exposure to HIV does not mean that one will contract HIV or AIDS, and it does not mean rapid progression. HIV-1 transmission rates are generally low and range from 0.1% to 10% per exposure. The interacting forces between viral and host factors influence whether a person will contract HIV infection, particularly the amount and virulence of the virus and the host’s response by T-cell–mediated cytotoxicity or by cytokines. In studies of patients with hemophilia who received tainted blood products, 10% to 25% of the individuals evaded infection. Because of genetic differences that either increase or decrease susceptibility to the infection, the risk of acquiring HIV and the response to infection also vary within populations. Some individuals, despite high-risk exposure, do not exhibit any signs of infection or immunodeficiency.

Researchers have identified an HIV resistance mutation of the CCR5 gene, called CCR5-delta 32, which is associated with natural resistance to HIV infection in certain people. When inherited from both parents, the mutant CCR5-delta 32 gene appears to protect individuals from infection even after multiple exposures. When only one gene is inherited, the progression to AIDS tends to be slower. The CCR5 gene is not equally distributed among people. Persons of Caucasian American and Caucasian-European descent have the highest number of mutant allele genes, approximately 10%, whereas Native American, African, and East Asian people have the lowest number of mutant alleles. A recent study on the protective effect of the CCR5-delta 32 allele in Mexican women found that there was an inverse relationship between allele frequency and the risk of HIV-1 transmission.

Researchers have also found that other mutations in the CCR5 gene can delay progression of HIV infection, such as polymorphism-2459 (A/G). Other proteins bind to CCR5 and demonstrate antiviral activity, such as macrophage inflammatory protein-1α (MIP-1α) and MIP-β, human neutrophil peptide 1 (hNP-1), as well as other chemokines. People who have fewer genes encoding CCL3L1, a potent HIV-blocking protein that interacts with CCR5, are more susceptible to HIV infection and have more rapid progression to AIDS, whereas individuals with natural killer (NK) cells that produce interferon-γ, tumor necrosis factor-α (TNF-α), CCL3, CCL4, and CCL5 are less likely to develop HIV infection. Because the susceptibility to and progression of HIV are multifactorial and exhibit significant interindividual variation, many aspects of the pathogenesis of HIV are still unknown.

Prevention of Transmission Prevention is essential, because effective management of HIV is expensive and a cure is not yet possible. However, one-time exposure to information or a single message is usually less successful than programs that teach prevention skills and reinforce positive behavior. The primary way to prevent transmission is to use safe sex practices. Safe sex practices include abstaining from sex, using a condom (barrier protection) during sexual intercourse, avoiding multiple sexual partners, and knowing the HIV status of all sexual partners. It is important that education regarding safe sex practices be tailored to appropriate age groups, ethnicity, culture, and sexual preference. Patient visits to health care providers are an excellent opportunity to encourage individual HIV protection.

Spermicides such as nonoxynol 9 or C31G do not inactivate HIV or other sexually transmitted microorganisms. No studies suggest any benefit from using progestins such as levonorgestrel (Norplant) or medroxyprogesterone (Depo-Provera), the diaphragm, or oral contracep- tives to prevent HIV transmission. The early use of antepartum and intrapartum antiretroviral therapy and avoidance of breast feeding can prevent maternal–child HIV infection.

HIV infection in drug users can be prevented with the use of sterile needles via improved access to clean needles and avoidance of dirty or shared needles. Such intervention includes needle/syringe exchange programs for IVDs and cleaning of dirty needles with bleach before

KEY POINTS • HIV disease is a primary immunodeficiency disorder caused by viral infection

of CD4+ cells. It is a major health concern because it causes chronic, severe, long-term disease in industrialized countries with access to medication, care, and prevention. In third-world countries where therapy is unavailable, the prognosis for HIV is very poor and death is more likely.

• HIV types 1 and 2 are retroviruses that primarily infect CD4+ lymphocytes and macrophages. HIV-1 is the primary causative virus infecting persons in Central Africa, the United States, Europe, and Australia.

• HIV is acquired primarily through sexual transmission via semen and vaginal and cervical secretions; through parenteral transmission via blood, blood products, and contaminated needles/syringes; and through perinatal transmission from an infected mother to her infant antepartum, intrapartum, and postpartum via breast milk.

• HIV is known to be present in but is not believed to be transmitted via urine, saliva, tears, cerebrospinal fluid, amniotic fluid, feces, or aerosols.

CHAPTER 12 HIV Disease and AIDS 239