INFLAMMATION DR RABIA RATHORE ASSISTANT PROFESSOR WEST MEDICAL

INFLAMMATION DR RABIA RATHORE ASSISTANT PROFESSOR WEST MEDICAL WARD MAYO HOSPITAL/K. E. M. U 1

DEFINITION OF INFLAMMATION � Inflammation is a defensive process that a living body initiates against local tissue damage. It takes the form of a complex reaction of blood vessels, certain plasma components and blood cells, and cellular and structural components of connective tissue. �Terms ending in the suffix “–itis” denote inflammation 2

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ETIOLOGY OF INFLAMMATION • Physical agents: � • extreme temperatures, electric shock, radiation, mechanical injures, etc. � • Chemical agents: � • Products of metabolism, acids, alkalis, drugs, tissue necrosis � • Biological agents: � • Microorganisms (bacteria, viruses, fungi), parasites (helmints, insects), immune cells and complexes. 5

ACUTE INFLAMMATION 6

�Causative agents - harmful bacteria or injury to tissue �Major cells involved - mainly neutrophils, basophils (in the inflammatory response), and eosinophils (response to parasites and worms), and mononuclear cells (macrophages, monocytes) �Primary mediators - eicosanoids, vasoactive amines �Onset (when does the inflammation start) - straight away �Duration - short-lived, only a few days �Outcomes - the inflammation either gets better (resolution), develops into an abscess, or becomes a chronic inflammation. 7

Terminology used in systemic inflammation and sepsis �Infection �Invasion of normally sterile host tissue by microorganisms �Bacteraemia �Viable bacteria in blood 8

Terminology used in systemic inflammation and sepsis �Systemic inflammatory response syndrome (SIRS) �The systemic inflammatory response to a variety of severe clinical insults. The response is manifested by two or more of the following: � Temperature >38°C or <36°C � Heart rate >90 beats/min � Respiratory rate >20 breaths/min or Pa. CO 2 <4. 3 k. Pa � White cell count >12 × 109/L, <4 × 109/L or >10% immature �forms. 9

Terminology used in systemic inflammation and sepsis �SIRS resulting from documented infection. �Severe sepsis �Sepsis associated with organ dysfunction, hypoperfusion or hypotensionbut are not limited to, lactic acidosis, oliguria or an acute alteration in mental state. 10

Terminology used in systemic inflammation and sepsis �Septic shock �Severe sepsis with hypotension (systolic BP <90 mm. Hg or a reduction of >40 mm. Hg from baseline) in the absence of other causes for hypotension and despite adequate fluid resuscitation. �Refractory shock �Shock unresponsive to conventional therapy (intravenous fluids and inotropic/vasoactive agents) within 1 h. 11

Terminology used in systemic inflammation and sepsis �Compensatory anti-inflammatory response syndrome (CARS) �Release of anti-inflammatory mediators which downregulate the inflammatory response. If excessive, may lead to inappropriate immune hyporesponsiveness. 12

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OUT COME OF ACUTE INFLAMMATION �Favorable � • Absorption, tissue repair (the most favorable outcome) � • Organization – scar formation �Unfavorable � • Acute organ insufficiency � • Abscess formation - pyonecrotic cavity � • Persistence of inflammation and chronicity 15

DIFFERENCE BETWEEN : TRANSUDATE 1. Transparent liquid � 2. Origin - congestion � 3. Up to 3% protein � 4. Isolated mesothelial cells, accidental single leukocytes and erythrocytes EXUDATE � 1. Slightly not quiet clear liquid � 2. Origin - inflammatory � 3. 3 -5% protein � 4. A small amount of leukocytes desquamated epithelium, mesothelium 16

EXUDATIVE INFLAMMATION � General definition: � Inflammations whose principal histologic findings include exudation of blood serum and extravasation of blood cells into the inflamed area. � Classification: � may be classified as follows according to the principal components of the exudate: � • serous � • catarrhal � • mucus, serous, purulent, hemorrhagic � • fibrinous � • croupous and diphtheretic � • purulent � • abscess, phlegmon and empyema � • hemorrhagic � • putrefactive 17

SEROUS INFLAMMATION 18

SEROUS INFLAMMATION �Definition: Exudative inflammation with exudate of fibrin-free serum. Examples: �Inflammation of serous membranes such as the pleura, pericardium, peritoneum, and joints; �Organ inflammation such as serous hepatitis, nephritis, myocarditis, encephalitis. 19

CASE SCENERIO NO: 1 �A 50 years old male presents in OPD with complaints of gradually increasing abdominal distension and pain abdomen. On examination the abdomen is protuberent, umblicus is everted with para umblical hernia , prominent striae and veins seen and fluid thrill is present while shifting dullness cannot be elicited due to massive ascites. 20

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�What is the differential diagnosis? 22

DIFFERENTIAL DIAGNOSIS �Chronic liver disease �Abdominal Tuberculosis �Hepatocellular carcinoma/Metastatic liver disease � Congestive cardiac failure �Chronic kidney disease 23

�How will you investigate him? 24

�Liver Function Test �PT/APTT �Ultrasound abdomen �Renal Function Test �ECG �Alpha Fetoprotein �Diagnostic Ascitic tap 25

CATARRHAL INFLAMMATION 26

CATARRHAL INFLAMMATION �Definition: Exudative inflammation occurring exclusively on the mucous membranes of the respiratory and gastrointestinal tracts and producing a watery exudate of serum and mucus �Subtypes: mucus (most frequent), serous, purulent, hemorrhagic �Etiologic factors: �— hypersensitivity reactions; �— bacterial and viral tissue injury; �— physical and chemical tissue injury. 27

EXAMPLE � • Acute rhinitis (common cold); � • Acute catarrhal bronchitis; � • Enteritis. 28

CASE SCENERIO NO: 2 � A young girl is having tiredness, slight pyrexia, malaise and a sore nose and pharynx. Sneezing and profuse, watery nasal discharge followed by thick muco- purulent secretions which is there for a week. What is your differential diagnosis? 29

DIFFERENTIAL DIAGNOSIS �Seasonal rhinitis �Perennial allergic rhinitis �Perennial non-allergic rhinitis with eosinophilia. Vasomotor rhinitis 30

FIBRINOUS INFLAMMATION 31

FIBRINOUS INFLAMMATION Definition: Exudative inflammation with exudation of fibrinogen-containing serum that polymerizes to fibrin outside the blood vessels. �Etiologic factors: �— Infectious toxic tissue injury; �— Tissue injury from physical trauma; �— Chemical and toxic tissue injury; �— Excretion of toxic metabolites (uremic toxins); �— Ischemic tissue injury. 32

TYPES OF FIBRINOUS INFLAMMATION v Fibrinous Parenchymal Inflammation v Fibrinous Serosal Inflammation v Fibrinous Mucosal Inflammation 33

FIBRINOUS PARENCHYMAL INFLAMMATION �CASE SCENERIO: NO. 3 �A 65 years of male has of high grade fever and productive cough with copious amount of foul smelling sputum for 5 days , now presented with complaints of hemoptysis. On examination breath sounds are reduced on left infra scapular region with a patch of broncial breathing and vocal resonance is increased. �What is the differential diagnosis? 34

DIFFERENTIAL DIAGNOSIS � Lobar Pneumonia � Collapse of Peripheral bronchus � fibrosis (localized) 35

�How will you investigate? 36

�ESR & BLOOD COMPLETE �SPUTUM EXAMINATION 37

FIBRINOUS SEROSAL INFLAMMATION �Definition: Exudative fibrinous inflammations of the serous membranes may occur as a reaction of the serosa to other underlying disorders (serositis) or in the presence of tissue injury occurring in the serosa (such as infarction). �Example: �Fibrinous pericarditis � Fibrinous pleuritis 38

CASE SCENERIO NO: 4 � A middle aged school teacher has fever and a sharp central chest pain exacerbated by movement, respiration and lying down. It is typically relieved by sitting forward. Auscultation revealed a frictional pericardial rub occurring in three phases corresponding to atrial systole, ventricular systole and ventricular diastole. �What is the diagnosis? 39

�Acute pericarditis. 40

�What are the causes of Acute Pericarditis? 41

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FIBRINOUS MUCOSAL INFLAMMATION �Definition: � In fibrinous inflammations in the mucosa, the fibrinous exudation process is usually preceded by superficial necrosis. �Types: � • Croupous Type � • Diphtheria Type 43

�Croupous Type: �Exudative inflammation in which a wide area of fibrinous exudate forms an easily removable pseudomembrane covering the necrosis, which is limited to the mucosal epithelium. �Example: Diphtheric laryngotracheitis 44

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Diphtheria Type : Exudative inflammation in which necrosis extending into the submucosa is covered by a wide area of fibrinous exudate in the form of an adhesive pseudomembrane that can only be forcibly removed. �Example: � • Antibiotic associated colitis : pseudomembranous colitis 46

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CASE SCENERIO NO: 5 �A middle aged man whose is taking injectible Clindamycin for cellulitis presents with bloody diarrhea for one day. Colonoscopic findings shows the mucosa is inflamed and ulcerated and was covered by an adherent membrane-like material. �What is the likely diagnosis? 48

�Pseudomembranous colitis 49

�How will you investigate him? 50

�Stool examination for Clostridium Difficile Toxin �Colonoscopy 51

PURULENT MUCOSAL INFLAMMATION 52

PURULENT MUCOSAL INFLAMMATION Definition: Inflammation with exudate consisting primarily of dead neutrophils and cellular debris. � Example: �Empyema � phlegmon � abscess 53

EMPYEMA �Definition: Suppurative inflammation in a body cavity. �Pathogenesis: An empyema usually occurs when a suppurative inflammation of an organ breaks through into an adjacent cavity. �Examples: � • Pericardial, peritoneal, and pleural empyema � • Gallbladder and appendiceal empyema; � • Middle ear and nasal sinus empyema; � • Pyosalpinx (pus in the uterine tube); � • Pyocephalus (pus in the cranial cavity); � • Hypopyon (pus in the anterior chamber of the eye). 54

CASE SCENARIO NO: 6 �A 35 years Immunocompromised male has high grade fever with purulent sputum. Upon arrival to the referral center, the patient was in mild respiratory distress with a respiratory rate of 44, Sp. O 2 94% to 98% on 2 L O 2 via nasal cannula. Lung examination revealed stony dull percussion note , decreased breath sounds on right side of the chest , with decreased vocal resonance. Fever did not responded to antibiotics for 3 days. Aspiration of the pleural fluid revealed frank pus. �What is the diagnosis? 55

EMPYEMA 56

PUTREFACTIVE INFLAMMATION 57

PUTREFACTIVE INFLAMMATION �Definition: � Exudative inflammation with putrid smell. �Etiologic factors – putrefactive anaerobic bacteria: � • Clostridium perfringens Morphology: massive necrosis without demarcation. �Clinical course: severe intoxication, sepsis, death 58

�A 60 years diabetic female presented with Local swelling and a sero sanguineous exudate over the foot. The skin initially was bronze in color, then progressed to a blueblack color with skin blebs and hemorrhagic bullae. Within hours, the entire region became markedly edematous. The Crepitus due to gas production can be palpated. There is typical putrid smell coming from the wound. �What is the diagnosis? 59

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�Gas Gangrene 61

�What is the causative organism? 62

�Clostridium perfringens 63

COURSES OF ACUTE INFLAMMATION � • Dissolution of the exudate � • Regeneration � • Secondary postinfectious disorders � • Chronic inflammation � • Hematogenous dissemination i. e SEPSIS 64

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