Astrakhan tick-borne spotted fever. Crimean hemorrhagic fever and preventive measures memo for the population Diagnosis of Astrakhan rickettsial fever

ARF (synonyms: Astrakhan spotted fever, Astrakhan fever, Astrakhan tick-borne spotted fever) is a rickettsiosis from the group of spotted fevers, transmitted by the tick Rhipicephalus pumilio and characterized by a benign course, the presence of a primary affect, fever, maculopapular rash.

ICD code -10

A77.8. Other spotted fevers.

Etiology (causes) of Astrakhan rickettsial fever

Cultivated in tissue culture, as well as in yolk sac developing chick embryo and in the affected mesothelial cells of laboratory animals (golden hamsters). Detailed Analysis The molecular genetic characteristics of rickettsia that cause ARL allows us to differentiate them from other pathogens of rickettsiosis of the LP group.

Epidemiology of Astrakhan rickettsial fever

The main epidemiologically significant factor in ARF foci is the constant and rather extensive infestation of dogs with the tick Rhipicephalus pumilio, the main reservoir and vector of rickettsiae. Tick ​​affected not only stray dogs, but also animals kept on a leash, and guard dogs that do not leave the yards.

Significant infestation by R. pumilio mites has been found in wild animals (eg hedgehogs, hares). From dogs, from the surface of the soil and plants, ticks can crawl onto humans. Ticks are unevenly distributed over the territory of the region depending on the microclimate, landscape, abundance and nature of the distribution of hosts: hedgehogs, hares, etc. Several decades ago, the tick R. pumilio was rarely found on agricultural and domestic animals, although the number of affected wild animals and the degree of their Northern Caspian were high. Under anthropogenic impact (commercial development of the Astrakhan gas condensate field, construction and commissioning of two stages of a gas condensate plant), a low-active natural focus of a previously unknown rickettsiosis turned into a manifest natural-anthropurgic focus of ARF.

Ticks retain rickettsia for life and transmit them transovarially.

Man gets infected when sucking a tick. Infection is possible by contact by rubbing the hemolymph of a crushed tick, its nymph or larvae into damaged skin, mucous membranes of the eyes, nose, or through an aerosol suspension. Natural susceptibility to ARL is age-related, residents are more likely to get sick rural areas Astrakhan region: adults of working age and the elderly (work in gardens, cottages, in agriculture), children of preschool and primary school age (greater contact with pets).

The disease is seasonal: April-October with a peak incidence in July-August, which is associated with an increase in the number of ticks at this time, mainly its juvenile forms (nymphs, larvae). The incidence of ARF was also detected in the regions adjacent to the Astrakhan region, in particular in Kazakhstan. Cases of ARF were noted among vacationers in the Astrakhan region after their departure.

Pathogenesis of Astrakhan rickettsial fever

At the site of tick suction, the pathogen begins to multiply and a primary affect is formed. Then the rickettsiae penetrate into the regional lymph nodes, where they also reproduce, accompanied by an inflammatory reaction. The next stage is rickettsiaemia and toxinemia, which form the basis of the pathogenesis of ARF. Morphologically, in the primary affect, necrotic lesions of the epidermis, neutrophilic microabscesses of the papillary layer of the skin are observed.

Acute vasculitis of vessels of different diameters develops with pronounced swelling of the endothelium, in places with fibrinoid necrosis, destruction of the elastic framework, and swelling of the collagen fibers of the dermis. Dilated lumen of the vessels is noted, some of the vessels contain blood clots. Vasculitis at first is local in nature, within the primary affect, and with the development of rickettsiemia, it becomes generalized. Mainly affects blood vessels microvasculature: capillaries, arterioles and venules. Disseminated thrombovascular disease develops.

Hemorrhagic elements are caused by perivascular diapedetic hemorrhages. By the beginning of recovery, proliferation of basal keratocytes begins in the epidermis; hyperpigmentation develops as a result of the breakdown of red blood cells, hemoglobin; infiltration and swelling of the endothelium are reduced; proliferate smooth muscle elements of the vessel wall; fibrinoid swelling of collagen fibers and edema of the dermis gradually disappear.

Rickettsia disseminate to various parenchymal organs, which is clinically manifested by an increase in the liver, spleen, and changes in the lungs.

Clinical picture (symptoms) of Astrakhan rickettsial fever

There are four periods of the disease:
incubation;
initial;
· height;
Reconvalescence.

The incubation period ranges from 2 days to 1 month.

The first sign of the disease is the primary affect in the place where the tick is sucked. The main symptoms of the disease are given in table. 17-46.

Table 17-46. Frequency and duration of individual symptoms in patients with Astrakhan rickettsial fever

The onset of the disease is acute, with the onset of fever. In half of the patients, fever is preceded by the appearance of a primary affect. In most cases, it is localized on the lower extremities, somewhat less often - on the trunk and in isolated cases - on the neck, head, hands, penis. The primary affect is predominantly single, occasionally two elements are observed. The formation of a primary affect is not accompanied by subjective sensations, but on the day of its appearance, slight itching and soreness are sometimes noted. Primary effect looks like pink spot, sometimes on a raised base, 5 to 15 mm in diameter. Point erosion appears in the central part of the spot, quickly covered with a dark brown hemorrhagic crust, which is rejected on the 8–23rd day of illness, leaving a point surface atrophy of the skin. At the base of the primary affect, unlike other tick-borne rickettsiosis, no infiltration is observed, the skin defect is exclusively superficial without deep necrotic changes in the dermis. Sometimes it is difficult to recognize among other elements of the rash.

Every fifth patient with primary affect has regional lymphadenitis. Lymph nodes do not exceed the size of a bean; they are painless, mobile, not soldered to each other.

The initial (pre-exanthematous) period of ACL lasts 2-6 days. It begins with an increase in body temperature, reaching 39-40 ° C by the end of the day; with the appearance of a feeling of heat, repeated chills, headache, joint and muscle pain, loss of appetite. Headache rapidly increases, in some patients it becomes excruciating and deprives them of sleep. Sometimes dizziness, nausea and vomiting occur. In the elderly, fever may be preceded by prodromal phenomena in the form of increasing weakness: weakness, fatigue, depressed mood. The febrile reaction is accompanied by moderate tachycardia. During this period, an increase in the liver is noted. The phenomena of scleritis and conjunctivitis are often recorded. Hyperemia of the mucous membrane of the posterior pharyngeal wall, tonsils, arches and uvula of the soft palate, in combination with complaints of sore throat and nasal congestion, is usually regarded as manifestations of acute respiratory infections, and in case of coughing, as bronchitis or pneumonia.

On the 3-7th day of fever, a rash appears and the disease goes into a peak period, which is accompanied by increased symptoms of intoxication.

The rash has a widespread character with localization on the skin of the trunk (mainly anterolateral sections), upper (mainly on the flexion surfaces) and lower extremities including palms and soles. On the face, a rash is rare, in cases with more pronounced intoxication.

The exanthema usually has a polymorphic maculopapular-papular, hemorrhagic character, in milder cases it can be monomorphic.

After the rash disappears, pigmentation persists. The rash on the palms and soles is papular in nature. Roseolous elements are usually abundant, occasionally single; pink or red, with a diameter of 0.5 to 3 mm. In a more severe course, a fusion of roseola is observed due to their abundance. Roseola often transforms into hemorrhagic spots, most often on the lower extremities.

In most patients, muffled heart tones and tachycardia are detected, corresponding to the severity of the temperature reaction, various rhythm disturbances (paroxysmal tachycardia, extrasystole, atrial fibrillation), and occasionally arterial hypotension are observed less often.

The tongue is covered with a grayish coating. Appetite is reduced up to anorexia.

Cheilitis phenomena are observed. In the early days of illness, transient diarrhea is possible. In every second patient, hepatomegaly is observed, on average, up to the 10–12th day of illness. The liver is painless, densely elastic consistency, its lower edge is even, the surface is smooth. Enlargement of the spleen almost never occurs.

Body temperature above 39 °C persists for 6–7 days; fever above 40 °C is rarely observed. On average, until the 7th day, many patients are worried about chills. The temperature curve is remitting, less often - constant or of the wrong type. The feverish period lasts an average of 11-12 days, ending in most cases with a shortened lysis.

With the normalization of temperature, a period of convalescence begins. The state of health of patients gradually improves, symptoms of intoxication disappear, appetite appears. In some recovering asthenization phenomena persist for a relatively long time.

ARL can be complicated by pneumonia, bronchitis, glomerulonephritis, phlebitis, metro- and rhinorrhagia, ITSH, acute cerebral circulation. In some patients, signs of toxic damage to the central nervous system are noted (nausea or vomiting with severe headache, bright facial erythema, stiff neck and Kernig's symptom, ataxia). In the study of cerebrospinal fluid, inflammatory changes are not detected.

The blood picture is usually uncharacteristic. Normocytosis is noted; there are no significant changes in the formula and indicators of phagocytic activity. In severe cases, leukocytosis, thrombocytopenia, signs of hypocoagulation are observed. Urinalysis in many cases reveals proteinuria, an increase in the number of leukocytes.

Diagnosis of Astrakhan rickettsial fever

Diagnostic criteria for ARF:
epidemiological data:
- seasonality of the disease (April-October),
- stay in a natural (anthropurgic) focus,
- contact with ticks (adults, larvae, nymphs);
· high fever;
Severe intoxication without the development of typhoid status;
arthralgia and myalgia;
Abundant polymorphic non-confluent and non-pruritic rash on the 2-4th day of illness;
The primary affect
scleritis, conjunctivitis, catarrhal changes in the pharynx;
Enlargement of the liver.

For the specific diagnosis of ARL, the reaction of RNIF with a specific antigen of the pathogen is used. Examine paired blood sera taken at the height of the disease and during the period of convalescence. The diagnosis is confirmed by a 4-fold or more increase in antibody titers. Also use the PCR method.

Differential Diagnosis

When examining for prehospital stage in 28% of patients with ARF were allowed diagnostic errors. ARL should be differentiated from typhus, measles, rubella, pseudotuberculosis, meningococcemia, Crimean hemorrhagic fever (CHF), leptospirosis, enterovirus infection(enteroviral exanthema), secondary syphilis (Table 17-47).

Table 17-47. Differential diagnosis of Astrakhan rickettsial fever

Diagnosis example

A77.8. Astrakhan rickettsial fever; moderate course (based on clinical, epidemiological, serological RNIF data).

Indications for hospitalization

Indications for hospitalization:
· high fever;
severe intoxication;
Tick ​​suction.

Treatment of Astrakhan rickettsial fever

Etiotropic therapy is carried out with tetracycline orally at a dose of 0.3-0.5 g four times a day or doxycycline on the first day 0.1 g twice a day, on subsequent days 0.1 g once. Rifampicin 0.15 g twice a day is also effective; erythromycin 0.5 g four times a day. Antibiotic therapy is carried out up to the 2nd day of normal body temperature inclusive.

With severe hemorrhagic syndrome (profuse hemorrhagic rash, bleeding gums, nosebleeds) and thrombocytopenia, ascorbic acid + rutoside, calcium gluconate, sodium menadione bisulfite, ascorbic acid, calcium chloride, gelatin, aminocaproic acid are prescribed.

Forecast

The prognosis is favorable. Patients are discharged 8-12 days after the normalization of body temperature.

Prevention of Astrakhan rickettsial fever

Specific prophylaxis of ARL has not been developed.

Disinsection of dogs and trapping of stray dogs matter.

In epidemic foci during the stay in nature during the ARF season, it is necessary to conduct self- and mutual examinations in order to detect ticks in a timely manner.

You should dress in such a way that the outer clothing is, if possible, of a single color, which makes it easier to search for insects. Pants are recommended to be tucked into knee socks, a shirt - into trousers; sleeve cuffs should fit snugly around the arms. You can not sit and lie on the ground without special protective clothing, spend the night in nature, if safety is not guaranteed.

To reduce the risk of ticks crawling from livestock and other animals onto humans, it is necessary to systematically inspect animals in the spring and summer period, remove stuck ticks with rubber gloves, and avoid crushing them. Ticks collected from animals should be burned.

A tick that has stuck to a person must be removed with tweezers along with the head; treat the bite site with a disinfectant solution; send the tick to the center of the State Sanitary and Epidemiological Supervision to determine its infectivity.

Passport part

Age: 58 years old

Place of residence:

Position: retired

Date of admission to the hospital:

Curation date:

Diagnosis of referring institution: Astrakhan rickettsial fever Diagnosis at admission: Astrakhan rickettsial fever

Preliminary clinical diagnosis: Astrakhan rickettsial fever

Final clinical diagnosis:

a) The main one: Astrakhan rickettsial fever (based on the clinical picture, epidemiological history, laboratory data - PCR diagnosis is positive from 08/30/2010)

b) Concomitant: Diabetes mellitus

For fever, weakness, headaches, vomiting, poor appetite, nausea, bitterness and dryness in the mouth, for the presence of a rash, for pain in the legs.morbid

The patient considers himself since August 25, 2010, when he began to notice fever, weakness, headaches and pain in the legs. Bring down the temperature with paracetamol. The patient's condition worsened, an ambulance was called, who was examined and hospitalized in the OIKB for the purpose of examination and treatment.

Epidemiological history

The patient is engaged in agricultural activities. On the eve of the disease, she worked on the land, where she felt a bite in the region of the left shoulder blade, after which itching and burning appeared, and the above complaints began to bother the patient.vitae

She was born in Astrakhan in 1952, on her second pregnancy. She was breastfed, started walking at 1.5 years old, started talking at 2 years old, was vaccinated on time. From the age of 7 she went to school, studied well, did not lag behind her peers in mental and physical development. Married, has two children. Material and living conditions are satisfactory. The food is good. Hepatitis, tuberculosis, sexually transmitted diseases denies. Allergic anamnesis is calm, has no bad habits. There were no blood transfusions prior to admission to the hospital. Geographical and hereditary anamnesis without features.praesens

The patient's condition is moderate. The position of the patient in bed is active. Consciousness is clear. The physique is correct, normosthenic type of constitution. The skin is of physiological color, high humidity, elasticity is reduced, there is a rash on the inner surface of the thighs and buttocks, in the region of the left shoulder blade there is a hyperimmic spot with a core in the center measuring 2x2 cm. The subcutaneous fat layer is moderately developed, evenly distributed, no edema.

Lymph nodes: submandibular, supraclavicular, subclavian without changes. Cervical, axillary, inguinal nodes are not enlarged, not limited in mobility. The general development of the muscular system is satisfactory, with no pain on palpation of the muscles. Muscle tone is the same on both sides. When examining the bones of the skull, chest, spine, limbs, pain and deformity are not noted. The joints of the correct configuration have pain with significant physical exertion. Active and passive movements in full.

Respiratory system.

Breathing is nasal, the shape of the nose is not changed. Thorax of the correct configuration of normosthenic type, chest type of breathing. Rhythmic breathing Respiratory rate 19 per minute. The respiratory movements of both sides of the chest are medium in depth, uniform and symmetrical. Auxiliary muscles are not involved in the act of breathing.

Percussion of the lungs

Comparative percussion of the lungs reveals a clear sound.

Topographic percussion data of the lungs:

The height of the apex in front: on the right 3 cm above the level of the clavicle, on the left 3 cm above the level of the clavicle, behind: at the level of the spinous process of the 7th cervical vertebra.

Inferior borders of the lungs:

Topographic lines on the right left parasternalis 5 intercostal space 5 intercostal space mediaclavicularis 6 intercostal space 6 intercostal space axilaris anterior 7 intercostal space 7 intercostal space axilaris media 8 intercostal space 8 intercostal space axilaris posterior 9 intercostal space 9 intercostal space scapularis 10 intercostal space 10 intercostal space paravertebralis spinous process of 11 thoracic vertebrae

Mobility of the lower edges of the lungs (see):

Topographic lines from the right to the left mediaclavicularis 2 2 4 2 2 4axilaris media 3 3 6 3 3 6scapularis 2 2 4 2 2 4

Auscultation of the lungs

Auscultation over the lungs is determined by vesicular breathing, wheezing is not auscultated.

The cardiovascular system.

The region of the heart is not changed, the apex beat is not visualized, it is palpated in the 5th intercostal space 1.5 cm medially from the left midclavicular line, 2 cm wide, of low moderate strength. There is no cardiac impulse.

Percussion of the heart

Limits of relative dullness of the heart:

Right - 1 cm outward from the right edge of the sternum (in the 5th intercostal space)

Upper - at the level of the 3rd intercostal space

Left - 1.5 cm medially from the left midclavicular line (in the 5th intercostal space), the configuration of the heart is not changed.

Limits of absolute dullness of the heart:

Right - left edge of the sternum

Upper - at the level of 4 ribs

Left - 2.5 cm medially from the left midclavicular line (in the 5th intercostal space)

Auscultation of the heart

The tones at the apex of the heart are muffled, rhythmic, there is a systolic murmur, the heart rate is 76 beats per minute. BP 110/70 mmHg Pulse 76 beats per minute, rhythmic, satisfactory filling and tension, normal size, the same on both sides.

The digestive system.

The mucous membrane of the oral cavity is pale pink in color. The tonsils are not enlarged, the tongue is red in color, slightly coated with white. The abdomen is not enlarged. On superficial palpation, the abdomen is soft and painless. Symptom of peritoneal irritation (Shchetkin - Blumberg) is negative. Soreness at the McBurney point is not observed. With deep palpation according to the Obraztsov-Strazhesko method, the sigmoid colon is palpated in the left iliac region, for 11 cm of a cylindrical shape with a diameter of 3 cm, dense elastic consistency, painless, does not rumble. The caecum is defined on the right as a moderately tense, slightly expanding cylinder with a rounded bottom, rumbling when pressed. The ileum is defined as a dense rumbling cylinder. The ascending and descending parts of the colon are painless on palpation. The transverse colon does not growl, painless. By methods of percussion, deep palpation, the lower border of the stomach is determined 4 cm below the navel, the lesser curvature and the pylorus are not palpable. The pancreas is not palpable. Abdominal auscultation reveals peristaltic bowel sounds. There is no splash noise.

Dimensions of hepatic dullness according to Kurlov. mediaclavicularis - 9 cm. mediana - 8 cm. costae sinistra - 7 cm.

The liver is palpated at the edge of the costal arch, the edge of the liver is soft, sharp, even. Smooth, moderately painful, gallbladder is not palpable. Protrusions and deformations in the area of ​​the liver are not detected. The spleen is enlarged, no protrusions and deformities are observed in its area.

Urinary organs.

Examination of the kidney area revealed no pathological changes¸ deformities. The kidneys are not palpable, the effleurage symptom is negative on both sides. There are no edemas on the face on the legs. The bladder percussion does not protrude above the pubis, is not palpable. There is no pain along the ureters.

Nervous system. Consciousness is clear, adequate. Thinking, memory, not changed. Meningeal signs, pathological reflexes are absent. The gait is stable, hearing, taste, vision and smell are not changed.

Endocrine system.

The thyroid gland is not enlarged, on palpation of a soft consistency, the parenchyma is mobile, painless. There is no exophthalmos. Secondary sexual characteristics correspond to age. Hair loss is noted, the type of hair growth is female.

Provisional clinical diagnosis:

Based on complaints: For fever, weakness, headaches, vomiting, poor appetite, nausea, bitterness and dryness in the mouth, for the presence of a rash, for pain in the legs.

Epidemiological history: The patient lives engaged in agricultural activities. On the eve of the disease, she worked on the land, where she felt a bite in the region of the left shoulder blade, after which itching, burning appeared and the patient began to be disturbed by the above described complaints.

objective research: in the region of the left shoulder blade there is a hyperimmic spot with a core in the center, 2x2 cm in size.

Survey plan.

General blood analysis.

General urine analysis.

Blood sugar test.

Blood chemistry.

PCR diagnostics.

Plasma analysis for malaria.

Feces on eggs worm.

General blood analysis.

Hb - 120 g/l

Erythrocytes - 3.84 * 1012

Color index - 0.9

Platelets - 157.0

Leukocytes - 6.1*109 g/l

Neutrophils: p / poison - 1, s / poison - 36

Lymphocytes - 29

Monocytes - 7

ESR 25 mm/h.

General urine analysis.

Quantity - 200 ml

Color: straw yellow

Relative density - 1015

Reaction - 5

Protein - no

Glucose - positive

Salts - oxalates

·Squamous epithelium 0-2 in p/z

Renal epithelium 0-1 in p/z

Glucose - 7.3 mmol/l

Blood chemistry.

ASAT - 40.25 IU / l

ALAT - 33.6 IU / l

Bilirubin total - 13.2

Direct bilirubin - 1.9

Thymol test - 3.3

PCR diagnosis is positive

Plasma test for malaria - negative

The Office of Rospotrebnadzor for the Astrakhan region informs that favorable climatic conditions in the region contribute to the activation of insects, including ticks that are carriers of Crimean hemorrhagic fever (CHF) and Astrakhan rickettsial spotted fever (ARPL).

Combined natural foci of CHF, ARPL, West Nile fever (WNF) and other infections have been registered in the region.

As of June 20, 2018, 1,716 victims of tick bites, including the carrier of KHF-383, turned to medical organizations in the Astrakhan region. Of all those who applied, 45.7% are children under the age of 14 (784 people).

As of June 20, 2018, 6 cases of CHF were registered in the Astrakhan region: in Astrakhan - 1 case and in 4 districts of the region: Narimanovskiy - 1 case, Kharabalinsky - 2 cases, Krasnoyarsk - 1 case. and Privolzhsky - 1 cl. All patients were infected when removing ticks from cattle and small cattle and crushing them, without using personal protective equipment.

Crimean hemorrhagic fever is a viral natural focal disease with a transmissible mechanism of infection. Translated from the Latin "hemorrhage" means bleeding.

How can you get infected?

Infection of a person with CHF occurs mainly through the bite of a carrier, by crushing ticks taken from domestic animals, as well as by contact with the blood of patients with CHF (through skin lesions, microcracks, wounds), when ticks are introduced by animals (dogs, cats) or people - on clothes, with flowers, branches, etc. (infection of people who do not visit the forest), when rubbing the virus into the skin when crushing a tick or scratching the bite site.

What are the main signs of the disease?

The disease begins acutely, accompanied by chills, severe headache, a sharp rise in temperature to 38-39 degrees, nausea, and vomiting. Relieve muscle pain. The main manifestations of CHF are hemorrhages into the skin, bleeding from the gums, nose, ears, uterus, stomach and intestines, which, if not promptly sought medical help, can lead to death. The first symptoms of the disease begin, like many viral infections, with a sharp increase in temperature and severe intoxication, accompanied by headache and muscle pain.

Who is susceptible to infection?

All people are susceptible to infection with CHF, regardless of age and gender.

Persons whose activities are associated with being in the forest are most at risk - workers caring for farm animals and growing crops, exploration parties, builders of roads and railways, oil and gas pipelines, power lines, topographers, hunters, tourists. Citizens become infected in suburban forests, forest parks, garden plots.

How can you protect yourself from CHF?

CHF disease can be prevented through individual prophylaxis.

Individual prophylaxis includes the use of special protective suits (for organized contingents) or adapted clothing that should not allow ticks to crawl through the collar and cuffs. The shirt should have long sleeves, which are reinforced at the wrists with an elastic band. They tuck the shirt into trousers, the ends of the trousers into socks and boots. The head and neck are covered with a scarf.

To protect against ticks, repellents are used - repellents and insecticidal crayons, which are used to treat open areas of the body and clothing.

Before using the drugs, you should read the instructions.

Each person, being in the natural focus of KHF during the season of insect activity, should periodically inspect his clothes and body on his own or with the help of other people, and remove the identified ticks. Inspection of children under the age of 14 should be carried out every 5 minutes, adolescents - every 10 minutes, adults - every 15 minutes.

Persons who have discovered a sucking tick should be under the supervision of specialists in the medical network for 2 weeks. Daily thermometry and timely access to a doctor at the first signs of the disease will reduce the risk of severe forms of the disease and prevent the development of hemorrhagic syndrome, which is the main cause of death.

In everyday life, the population can influence the reduction in the number of ticks by actively participating in cleaning up the territories of summer cottages from last year's grass, dead wood, garbage, as well as the adjacent territory to the summer cottage. As a preventive measure, it is recommended to carry out anti-tick treatment of farm animals by contacting veterinarians for help. It is advisable not to allow grazing of farm animals on the territory of summer cottages, summer health facilities, school grounds, etc.

How to remove a tick?

If a tick is found, it must be removed as soon as possible. To do this, you can contact the medical institution at the place of residence (on weekends and holidays, to the emergency departments of the nearest hospitals and emergency room).

It should be removed very carefully so as not to cut off the proboscis, which is deeply and strongly strengthened for the entire period of suction.

When removing a tick, the following guidelines should be observed:

Grab the tick with tweezers or fingers wrapped in clean gauze (cellophane) as close as possible to its mouth apparatus and holding it strictly perpendicular to the bite surface, turn the body of the tick around the axis, remove it from the skin,