TYPES OF CONNECTIVE TISSUE (Fibers)

The fibrous components are elongated structures formed from proteins that polymerize after secretion from fibroblasts. The three main types of fibers include collagen, reticular, and elastic fibers. Collagen and reticular fibers are both formed by proteins of the collagen family, and elastic fibers are composed mainly of the protein elastin. These fibers are distributed unequally among the different types of connective tissue, with the predominant fiber type usually responsible for conferring specific tissue properties.

Loose connective tissue - delicate, flexible, not very resistant to stress, well vascularized. All types of connective tissue cells present. Majority are fibroblasts and macropahges. Collagen, elastic, and reticular fibers present. In certain organs (I, ntestine) and in certain disease conditions, numerous lymphocytes may be present.

Dense connective tissue - Clear predominance of collagen fibers at expense of ground substance. Fewer cells than loose. Less flexible and more resistant to stress. When collagen bundles are present without apparent orientation, called dense irregular connective tissue. When oriented in parallel arrays, called dense regular connective tissue.

Elastic tissue - bundles of thick, parallel elastic fibers. Small amount of loose connective tissue around each bundle. Yellow colour, thinner than type I collagen fibers and form sparse networks interspersed with collagen bundles in many organs.

o Elastic fibers have physical properties similar to those of rubber, allowing tissues to be stretched or distended and return to their original shape. In the wall of large blood vessels, especially arteries, elastin also occurs as fenestrated sheets called elastic lamellae. Elastic fibers and lamellae are not strongly acidophilic and stain poorly with H&E; they are stained more darkly than collagen in other stains such as orcein and aldehyde fuchsin (Figure 5–13). Elastic fibers (and lamellae) are a composite of fibrillin microfibrils embedded in a larger mass of cross-linked elastin. Both components are secreted from fibroblasts (and smooth muscle cells in vascular walls) and produce elastic fibers in a stepwise manner. Initially, microfibrils with diameters of 10 nm form from the protein fibrillin (350 kDa) and from several other glycoproteins. The microfibrils act as scaffolding upon which elastin is deposited in the second step of elastic fiber formation. Elastin accumulates between the microfibrils, surrounding most of these, and eventually comprises most of the elastic fiber. Stages of elastic fiber formation are shown in Figure 5-14. The properties of elastic fibers and lamellae result from the structure of the 60 kDa elastin subunits and the unique cross-links holding them together. Elastin molecules are rich in glycine, proline, and lysine, giving much of the protein a random-coil conformation (like that of natural rubber). Many lysines are present as pairs. During deposition on microfibrils the enzyme lysyl oxidase converts the paired lysines’ amino groups to aldehydes. Oxidized lysines on two different elastin molecules then condense as a desmosine ring that acts as a covalent cross-link between the polypeptides, which maintain their rubberlike properties (Figure 5–15). Elastin resists digestion by most proteases, but it is hydrolyzed by pancreatic elastase.

Reticular tissue - a specialized loose connective tissue with reticular cells that form a fine matrix of reticular fibers. Provides a structural framework for hematopoietic organs such as bone marrow and spleen. Reticular Fibers Found in delicate connective tissue of many organs, reticular fibers consist mainly of collagen type III. This collagen forms an extensive network (reticulum) of extremely thin (diameter 0.5-2 μm), heavily glycosylated fibers. Reticular fibers are seldom visible in hematoxylin and eosin (H&E) preparations but are characteristically stained black by impregnation with silver salts (Figure 5–12) and are termed

argyrophilic (Gr. argyros, silver). Reticular fibers are also periodic acid-Schiff (PAS) positive, which, like argyrophilia, is due to the high content of sugar chains bound to type III collagen. Reticular fibers contain up to 10% carbohydrate as opposed to 1% in most other collagen fibers. Reticular fibers produced by fibroblasts occur in the reticular lamina of basement membranes and typically also surround adipocytes, smooth muscle and nerve fibers, and small blood vessels. Delicate reticular networks serve as the supportive stroma for the parenchymal secretory cells and rich microvasculature of the liver and endocrine glands. Abundant reticular fibers also characterize the stroma of hemopoietic tissue (bone marrow) and some lymphoid organs (eg, spleen and lymph nodes) where they support rapidly changing populations of proliferating cells and phagocytic cells.

Mucous tissue - a lot of amorphous ground substance composed mainly of hyaluronic acid (glycosaminoglycan). Forms a jellylike tissue. Mainly fibroblasts present. Found in umbilical cord and pulp of young teeth. Reticular Tissue In reticular tissue fibers of type III collagen (see Figure 5–12) form a delicate 3D network that supports various types of cells. The fibrous network of this specialized connective tissue is produced by modified fibroblasts called reticular cells that remain associated with and partially covering the fibers (Figure 5–23). The loose disposition of glycosylated reticular fibers provides a framework with specialized microenvironments for cells in hemopoietic tissue and some lymphoid organs (bone marrow, lymph nodes, and spleen). The resulting cell-lined system creates a meshwork (see Figure 5–12) for the passage of lymphocytes and lymph. Macrophages and other cells of the mononuclear phagocyte system are also dispersed within these reticular tissues to monitor cells formed there or passing through and to remove debris. Mucoid Tissue Mucoid (or mucous) connective tissue is another embryonic type of connective tissue, found mainly in the umbilical cord and fetal organs. With abundant ground substance composed chiefly of hyaluronic acid, mucoid tissue is jellylike with sparse collagen fibers and scattered fibroblasts (Figure 5–24). Mucoid tissue is the principal component of the umbilical cord, where it is referred to as Wharton’s jelly. A similar form of connective tissue is also found in the pulp cavities of young teeth, which remain as a postnatal source of mesenchymal stem cells.

Adipose tissue (adipocytes/ large fat cells) - are connective tissue cells that are specialized for lipid synthesis and storage.

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Collagen The collagens constitute a family of proteins selected during evolution for their ability to form a variety of extracellular structures. The various fibers, sheets, and networks made of collagens are all extremely strong and resistant to normal shearing and tearing forces. Collagen is a key element of all connective tissues, as well as epithelial basement membranes and the external laminae of muscle and nerve cells. Collagen is the most abundant protein in the human body, representing 30% of its dry weight. A major product of fibroblasts, collagens are secreted by several other cell types and are distinguishable by their molecular compositions, morphologic characteristics, distribution, functions, and pathologies. A family of 28 collagens exists in vertebrates, the most important of which are listed in Table 5–3. They can be grouped into the following categories according to the structures formed by their interacting subunits:

Fibrillar collagens, notably collagen types I, II, and III, have subunits that aggregate to form large fibrils clearly visible in the electron or light microscope (Figure 5–8). Collagen type I, the most

abundant and widely distributed collagen, forms large, eosinophilic bundles usually called collagen fibers. These often densely fill the connective tissue, forming structures such as tendons, organ capsules, and dermis.

Sheet-forming collagens such as type IV collagen have subunits produced by epithelial cells and are the major structural proteins of external laminae and the basal lamina in all epithelia. Linking/anchoring collagens are short collagens that link fibrillar collagens to one another (forming larger fibers) and to other components of the ECM. Type Vii collagen binds type IV collagen and anchors the basal lamina to the underlying reticular lamina in basement membranes (see Figure 4–3).

Collagen synthesis occurs in many cell types but is a specialty of cells that produce the various kinds of connective tissue. The initial procollagen α chains are made in the cells’ abundant RER. The collagen gene family is very large, and many different α chains have been identified, varying in length and sequence. In the ER three α chains are selected, aligned, and stabilized by disulfide bonds at their carboxyl terminals, and folded as a triple helix, which is the defining feature of collagens. The triple helix undergoes exocytosis and is

cleaved to a rodlike procollagen molecule (Figure 5–9) that is the basic subunit from which the fibers or sheets are assembled. These subunits may be homotrimeric, with all three chains identical, or heterotrimeric, with two or all three chains having different sequences. Different combinations of procollagen α chains produce the various types of collagen with different structures and functional properties.

An unusually large number of posttranslational processing steps are required to prepare collagen for its final assembly in the ECM. These steps have been studied most thoroughly for type I collagen,

which accounts for 90% of all the body’s collagen. The most important parts of this process are summarized in Figure 5–10 and here:

1. The procollagen α chains are produced on polyribosomes of the RER and translocated into the cisternae, where the signal peptide is clipped off. Collagens typically have long central domains rich in proline and lysine; in type I collagen every third amino acid is glycine.

2. Hydroxylase enzymes in the ER cisternae add hydroxyl groups to some prolines and lysines in important reactions that require O2, Fe2+, and ascorbic acid (vitamin C) as cofactors.

3. Glycosylation of some hydroxylysine residues also occurs, with the various collagen types having different amounts of bound galactose.

4. Both the amino-and carboxyl-terminal sequences of α chains have globular structures that lack the gly-X-Y repeats. In the RER the C-terminal regions of three selected α chains (α1, α2) are stabilized by cysteine disulfide bonds, which align the three polypeptides and facilitates their central domains folding as the triple helix. With its globular terminal sequences intact, the trimeric procollagen molecule is transported through the Golgi apparatus, packaged in vesicles and secreted.

5. Outside the cell, specific proteases called procollagen peptidases remove the terminal globular peptides, converting the procollagen molecules to collagen molecules. These now self-assemble (an entropy-driven process) into polymeric collagen fibrils, usually in specialized niches near the cell surface.

6. Certain proteoglycans and collagens (types V and XII) associate with the new collagen fibrils, stabilize these assemblies, and promote the formation of larger fibers from the fibrils.

7. Fibrillar structure is reinforced and disassembly is prevented by the formation of covalent crosslinks between the collagen molecules, a process catalyzed by the enzyme lysyl oxidase. The other fibrillar and sheetlike collagens are formed in processes similar to that described for collagen type I and stabilized by linking or anchoring collagens. Because there are so many steps in collagen biosynthesis, there are many points at which the process can be interrupted or changed by defective enzymes or by disease processes (Table 5–4).

Type I collagen fibrils have diameters ranging from 20 to 90 nm and can be several micrometers in length. Adjacent rodlike collagen subunits of the fibrils are staggered by 67 nm, with small gaps (lacunar regions) between their ends (Figure 5–11). This structure produces a characteristic feature of type I collagen visible by EM: transverse striations with a regular periodicity (Figure 5–11). Type I collagen fibrils assemble further to form large, extremely strong collagen fibers that are bundled by linking collagens and proteoglycans. Collagen type II (present in cartilage) occurs as fibrils but does not form fibers or bundles. Sheet-forming collagen type IV subunits assemble as a lattice-like network in epithelial basal laminae.

When present in large numbers (eg, in tendons or the eye’s sclera region), bundles of collagen appear white. The highly regular orientation of subunits makes collagen fibers birefringent under the polarizing microscope (see Figure 1–7). In the light microscope, collagen fibers are acidophilic; they stain pink with eosin and blue with Mallory trichrome stain, and red with Sirius red. Because of the long and tortuous course of collagen bundles, their length and diameter are better studied in spread preparations than in histologic sections (see Figure 1–7). Mesentery is frequently used for this purpose; when spread on a slide, this structure is sufficiently thin to let the light pass through; it can be stained and examined directly under the microscope. Collagen turnover and renewal in normal connective tissue is generally a very slow but ongoing process. In some organs, such as tendons and ligaments, the collagen is very stable, whereas in others, as in the periodontal ligament surrounding teeth, the collagen turnover rate is high. To be renewed, the collagen must first be degraded. Degradation is initiated by specific enzymes called collagenases, which are members of an enzyme class called matrix metalloproteinases (MMPs). Collagenases clip collagen fibrils or sheets in such a way that they are then susceptible to further degradation by nonspecific proteases. Various MMPs are secreted by macrophages and play an important role in remodeling the ECM during tissue repair.

GROUND SUBSTANCE The ground substance of the ECM is a highly hydrated (with much bound water), transparent, complex mixture of macro-molecules, principally of three classes: glycosaminoglycans (GAGs), proteoglycans, and multiadhesive glycoproteins. It fills the space between cells and fibers in connective tissue and, because it is viscous, acts as both a lubricant and a barrier to the penetration of invaders. Many macromolecules and physical properties of ground substance profoundly influence a variety of cellular activities. When adequately fixed for histologic analysis, its components aggregate and precipitate in the tissues as granular material that is observed in TEM preparations as electrondense filaments or granules (Figure 5–16).

GAGs (also called mucopolysaccharides) are long polysaccharides consisting of repeating disaccharide units, usually a uronic acid and a hexosamine. The hexosamine can be glucosamine or galactosamine, and the uronic acid can be glucuronic or iduronic acid. The largest, almost unique, and most ubiquitous GAG is hyaluronic acid (HA or hyaluronan). With a molecular weight from 100s to 1000s kDa, hyaluronic acid is a long polymer of the disaccharide glucosamine-glucuronate. It is synthesized directly into the ECM by an enzyme complex, hyaluronate synthase, located in the cell membrane of many cells. Hyaluronic acid forms a dense, viscous network of polymers, which binds a considerable amount of water, giving it an important role in allowing diffusion of molecules in connective tissue and in lubricating various organs and joints. All other GAGs are much smaller (10-40 kDa), sulfated, covalently attached to proteins (as parts of proteoglycans), and are synthesized in Golgi complexes. The four major GAGs found in proteoglycans are dermatan sulfate, chondroitin sulfates, keratan sulfate, and heparan sulfate, all of which have different disaccharide units and tissue distributions (Table 5–5). Like hyaluronic acid, these GAGs are intensely hydrophilic, contributing to the viscosity of ground substance, and are polyanions, binding a great number of cations (usually sodium) by electrostatic (ionic) bonds.

Proteoglycans are composed of a core protein to which are covalently attached various numbers and combinations of the sulfated GAGs. Like glycoproteins, they are synthesized on RER, mature in the Golgi, where the GAG side chains are added, and secreted from cells by exocytosis. Unlike glycoproteins, some proteoglycans, such as the major cartilage constituent aggrecan, contain a greater mass of polysaccharide chains than polypeptide. These structural differences between a typical glycoprotein and aggrecan are shown in Figure 5-17.

Proteoglycans are distinguished by their diversity, which is generated in part by enzymatic differences in the Golgi complexes. A region of ECM may contain

several different core proteins, each with one or many GAGs of different lengths and composition. A small proteoglycan, decorin, has few GAG side chains and binds fibrils of type I collagen. Cell surface proteoglycans such as syndecan have transmembrane core proteins and serve as additional attachments of the cell to the ECM. One of the best known proteoglycans, aggrecan, is very large (250 kDa), with a core protein bearing many chondroitin sulfate and keratan sulfate chains. Aggrecan is bound via a link protein to polymer of hyaluronic acid (Figure 5–17). In cartilage aggrecan-hyaluronate, complexes fill the space between collagen fibers and cells and contribute greatly to the physical properties of this tissue. GAGs bind large amounts of water, which causes the poly-anions to swell and occupy a large space in the tissue. Embryonic mesenchyme (Figure 5–1) is very rich in hyaluronate and water, producing the characteristic wide spacing of cells and a matrix ideal for cell migrations and growth. Both matrix-linked and cell surface proteoglycans also bind and sequester certain signaling proteins, for example fibroblast growth factor (FGF). Degradation of proteoglycans during the early phase of tissue repair releases these stored growth factors that then stimulate new cell growth and ECM synthesis.

The third class of ground substance components, the multiadhesive glycoproteins, all have

multiple binding sites for cell surface receptors (integrins) and for other matrix macromolecules. The adhesive glycoproteins are very large molecules with branched oligosaccharide chains and have important roles in the adhesion of cells to their substrate. The large (200-400 kDa), trimeric, crossshaped glycoprotein laminin provides adhesion for epithelial and other cells, with binding sites for integrins, type IV collagen, and specific proteoglycans. As shown in Figure 5-18a, all basal and external laminae are rich in laminin, which is essential for the assembly and maintenance of these structures.

Fibronectin (L. fibra, fiber + nexus, interconnection), synthesized largely by fibroblasts, is a 235-270 kDa dimeric molecule, has binding sites for collagens and certain GAGs, and forms insoluble fibrillar networks throughout connective tissue (Figure 5–18b). The fibronectin substrate provides specific binding sites for integrins and is important both for cell adhesion and cellular migration through the ECM. The integrin family of integral membrane proteins act as matrix receptors for specific sequences on laminin, fibronectin, some collagens, and certain other ECM proteins (Figure 5–19). Integrins bind their ligands in the ECM with relatively low affinity, allowing cells to explore their environment without losing attachment to it or becoming glued to it. They are heterodimers of two transmembrane polypeptides: the α and β chains. Great diversity in the

subsets of integrin α and β chain cells express allows the cells to have different specific ligands preferentially.

Cytoplasmic portions of integrins associate with the peripheral membrane proteins talin and vinculin, which together bind actin filaments (Figure 5–19). In this way integrins mediate physical connections between ECM components and the cytoskeleton of cells in connective tissue, which allows the cells to monitor many physical aspects of their microenvironment. These connections between cells and the ECM exert effects in both directions and are important for the physical orientation of both cells and fibers. Integrins and other proteins associated with intermediate filaments form the hemidesmosomes of epithelia (see Chapter 4); clustered integrin-microfilament complexes in fibroblasts form structures called focal adhesions that can be localized by TEM or immunocytochemistry. This type of adhesive junction is typically present at the ends of actin filaments bundled by a-actinin as cytoplasmic stress fibers. Focal adhesion kinases provide a mechanism by which pulling forces or other physical properties of the ECM can change activities in the cytoplasm. In addition to the hydrated ground substance of connective tissue, a small quantity of free interstitial fluid, with ion composition similar to that of blood plasma, is also present. Interstitial fluid contains plasma proteins of low molecular weight that pass through the thin walls of capillaries, the smallest blood vessels. Although only a small proportion of connective tissue proteins are plasma proteins, it is estimated that as much as one-third of the body’s plasma proteins are stored in the matrix of connective tissue because of its volume and wide distribution.

Capillaries in connective tissue throughout the body bring the various nutrients required by cells and carry away their metabolic waste products to the detoxifying and excretory organs, the liver and kidneys. Interstitial water provides the solvent for these substances. Two forces act on the water in capillaries (Figure 5–20):

The hydrostatic pressure of the blood caused by the pumping action of the heart, which forces water out across the capillary wall The colloid osmotic pressure produced by plasma proteins such as albumin, which draws water back into the capillaries

The colloid osmotic pressure exerted by the blood proteins—which are unable to pass through the capillary walls—is not counterbalanced by outside pressure and tends to pull back into the vessel the water forced out by hydrostatic pressure (Figure 5–20). (Because the ions and low-molecular-weight compounds that pass easily through the capillary walls have similar

concentrations inside and outside these blood vessels, the osmotic pressures they exert are approximately equal on either side of the capillaries and cancel each other.) The quantity of water drawn back into capillaries is often less than that which was forced out. Normally this excess fluid does not accumulate in connective tissue but drains continuously into lymphatic capillaries that eventually return it to the blood. Discussed later with the lymphoid system, lymphatic capillaries originate in connective tissue as delicate, open-ended endothelial tubes (Figure 5–20). TYPES OF CONNECTIVE TISSUE Different combinations and densities of the cells, fibers, and extracellular macromolecules just described produce graded variations in histological structure within connective tissue. Descriptive names or classifications used for the various types of connective tissue denote either a major component or a structural characteristic of the tissue. Table 5–6 gives a classification commonly used for the main types of connective tissue. Adipose tissue, an important specialized connective tissue, and two other supporting tissues, cartilage and bone, will be covered in Chapters 6, 7, and 8.

Connective Tissue Proper In adults there are two general classes of connective tissue proper, loose and dense, terms that refer to amounts of collagen present (Figure 5–21). Loose connective tissue is very common and generally supports epithelial tissue. It comprises a thick layer (the lamina propria) beneath the epithelial lining of the digestive system and fills the spaces between muscle and nerve fibers (Figure 5–18a). Usually well-vascularized whatever their location, thin layers of loose connective tissue surround most small blood vessels of the body.

Also called areolar tissue, the loose connective tissue typically contains cells, fibers, and ground substance in roughly equal parts. The most numerous cells are fibroblasts, but the other types of connective tissue cells are also present, along with nerves and blood vessels. Collagen fibers predominate, but elastic and reticular fibers are also present. With a moderate amount of ground substance, loose connective tissue has a delicate consistency; it is flexible and not very resistant to stress. Dense connective tissue is adapted to offer stress resistance and protection. It has the same components found in loose connective tissue, but with fewer cells and a clear predominance of collagen fibers over ground substance. Dense connective tissue is less flexible and far more resistant to stress than loose connective tissue. In dense irregular connective tissue bundles of collagen fibers appear randomly interwoven, with no definite orientation. The collagen fibers form a tough three-dimensional network, providing resistance to stress from all directions. Dense irregular connective tissue is often found closely associated with loose connective tissue, with the

two types frequently grading into each other and making distinctions between them somewhat arbitrary (Figure 5–21). The type I collagen bundles of dense regular connective tissue are arranged according to a definite pattern, with fibers and fibroblasts aligned in parallel for resistance to prolonged or repeated stresses exerted in the same direction (Figure 5–22).

Common examples of dense regular connective tissue, such as tendons and ligaments, are strong, flexible straps or cords that hold together components of the musculoskeletal system. Consisting almost entirely of densely packed collagen fibers, they are white in the fresh state and almost inextensible. The parallel, closely packed bundles of collagen are separated by very little ground substance (Figure 5–22a). The fibrocytes have elongated nuclei lying parallel to the fibers and sparse cytoplasmic folds that envelop portions of the collagen bundles (Figure 5–22b). The cytoplasm of these “tendinocytes” is rarely revealed in H&E stains, not only because it is sparse but also because

it stains the same color as the fibers. Some ligaments, such as the yellow ligaments of the vertebral column, also contain abundant parallel elastic fiber bundles. The collagen bundles of tendons vary in size and are enveloped by small amounts of irregular connective tissue containing small blood vessels and nerves. Overall, however, tendons are poorly vascularized and repair of damaged tendons is very slow. In some tendons, the dense irregular connective tissue sheath is covered by flattened synovial cells of mesenchymal origin, which produce lubricant fluid (similar to the fluid of synovial joints, Chapter 8) containing water, proteins, hyaluronate, and other GAGs.

MEDICAL APPLICATION

Some cells in mesenchyme are multipotent stem cells potentially useful in regenerative medicine after grafting to replace damaged tissue in certain patients. Mesen-chyme-like cells remain present in some adult connective tissues, including that of tooth pulp and some adipose tissue, and are being investigated as possible sources of stem cells for therapeutic repair and organ regeneration.

The regenerative capacity of connective tissue is clearly observed in organs damaged by ischemia, inflammation, or traumatic injury. Spaces left after such injuries, especially in tissues whose cells divide poorly or not at all (eg, cardiac muscle), are filled by connective tissue, forming dense irregular scar tissue. The healing of surgical incisions and other

wounds depends on the reparative capacity of connective tissue, particularly on activity and growth of fibroblasts. In some rapidly closing wounds, a cell called the myofibroblast, with features of both fibroblasts and smooth muscle cells, is also observed. These cells have most of the morphologic characteristics of fibroblasts but contain increased amounts of actin microfilaments and myosin and behave much like smooth muscle cells. Their activity is important for the phase of tissue repair called wound contraction.

Besides their function in turnover of ECM fibers, macrophages are key components of an organism’s innate immune defense system, removing cell debris, neoplastic cells, bacteria, and other invaders. Macrophages are also important antigen-presenting cells required for the activation and specification of lymphocytes. When macrophages are stimulated (by injection of foreign substances or by infection), they change their morphologic characteristics and properties, becoming activated macrophages. In addition to showing an increase in their capacity for phagocytosis and intracellular digestion, activated macrophages exhibit enhanced metabolic and lysosomal enzyme activity. Macrophages are also secretory cells producing an array of substances, including various enzymes for ECM breakdown and various growth factors or cytokines that help regulate immune cells and reparative functions. When adequately stimulated, macrophages may increase in size and fuse to form multinuclear giant cells, usually found only in pathologic conditions.

Plasma cells are derived from B lymphocytes and are responsible for the synthesis of immunoglobulin antibodies. Each antibody is specific for the one antigen that stimulated the clone of B cells and reacts only with that antigen or molecules resembling it (see Chapter 14). The results of the antibody-antigen reaction are variable, but they usually neutralize harmful effects caused by antigens. An antigen that is a toxin (eg, tetanus, diphtheria) may lose its capacity to do harm when it binds to its specific antibody. Bound antigen-antibody complexes are quickly removed from tissues by phagocytosis.

Increased vascular permeability is caused by the action of vasoactive substances such as histamine released from mast cells during inflammation. Increased blood flow and vascular permeability produce local swelling (edema), redness, and heat. Pain is due mainly to the action of the chemical mediators on nerve endings. All these activities help protect and repair the inflamed tissue. Chemotaxis (Gr. chemeia, alchemy

+ taxis, orderly arrangement), the phenomenon by which specific cell types are attracted by specific molecules, draws much larger numbers of leukocytes into inflamed tissues.

Normal collagen function depends on the expression of many different genes and adequate execution of several posttranslational events. It is not surprising, therefore, that many pathologic conditions are directly attributable to insufficient or abnormal collagen synthesis. A few such genetic disorders or conditions are listed in TABLE 5–4.

Fibrillins comprise a family of proteins involved in making the scaffolding necessary for the deposition of elastin. Mutations in the fibrillin genes result in Marfan syndrome, a disease characterized by a lack of resistance in tissues rich in elastic fibers. Because the walls of large arteries are rich in elastic components and because the blood pressure is high in the aorta, patients with this disease often experience aortic swellings called aneurysms, which are life-threatening conditions.

The degradation of proteoglycans is carried out by several cell types and depends in part on the presence of several lysosomal enzymes. Several disorders have been described, including a deficiency in certain lysosomal enzymes causing degradation of certain GAGs, with the consequent accumulation of these macromolecules in tissues. The lack of specific hydrolases in the lysosomes has been found to be the cause of several disorders, including the Hurler, Hunter, S anfilippo, and Morquio syndromes. Because of their high viscosity, HA and proteoglycans tend to form a barrier against bacterial penetration of tissues. Bacteria that produce hyaluronidase, an enzyme that hydrolyzes hyaluronic acid and disassembles proteoglycans complexes, reduce the viscosity of the connective tissue ground substance and have greater invasive power.

Edema is the excessive accumulation of water in the extracellular spaces of connective tissue. This water comes from the blood, passing through the capillary walls that become more permeable during inflammation and normally producing slight swelling.

Overuse of tendon-muscle units can result in tendonitis, characterized by inflammation of the tendons and their attachments to muscle. Common locations are the elbow, the Achilles tendon of the heel, and the shoulder rotator cuff. The swelling and pain produced by the localized inflammation restricts the affected area’s normal range of motion and can be relieved by injections of antiinflammatory agents such as cortisone. Fibroblasts eventually repair damaged collagen bundles of the area.

Keloid is a local swelling caused by abnormally large amounts of collagen that form in scars of the skin. It often occurs in individuals of African descent and can be a troublesome clinical problem to manage. Not only can they be disfiguring, but excision is almost always followed by recurrence.