Forum Replies Created
Mel,
I am a bit confused. The CBC I commented on previously was from 9-2. The CBC you are now referring to is from 8-23. There are only two files in Urgent Advice. No file for today 9-5?
Anyway, the CBC from 8-23 is markedly different from the CBC done 5 days later on 9-2. That’s not unusual to see and explains a lot.
There is a rapid increase in the overall WBC count from 8-23 to 9-2. The values were normal on 8-23. This indicates that something occurred very recently to cause high WBC count. But, as we discussed before, this could be new “Baby blood cells” that look like WBC but are not. If you did a test today on 9-5 we will know more about this.
There was a marked change in the HCT from 9.23% on 8-23 to 24.6% on 9-2. What is this and what does it mean.
Hematocrit is the value that measures the AMOUNT of red blood cells as a percentage of the total blood (in this case whatever is in the blood sample being examined.) So therefore each blood item has a percentage of the whole and together they equal 100%. This is how the laser analyzer evaluates the sample. Hematocrit is somewhat equivalent to the PCV packed cell volume, but slightly different. The normal average HCT is about 38-50%, with some variables according to breeds. I believe Beagles have a slightly higher normal HCT than other breeds. But in any case, if he reaches 38% he will be considered to have a normal amount of HCT.
The PCV value is determined VISUALLY, by holding a small tube of blood up against a chart and reading the values on the chart. See this page:
https://www.secondchanceaihadogs.com/AIHA_Terms/pcv-packed-cell-volume
I have found that in our very sick dogs the PCV is a more accurate measurement and I always recommend that an owner request that the tech, when drawing blood for the CBC, also draw enough to perform the test by hand: the PCV. There can be as much as 3-6 % difference in dogs who have experienced AIHA IMHA and bone marrow failure. The PCV is more accurate and usually has a higher (correct) value.
So when a dog has AIHA IMHA there have been significant changes to the normal blood elements. When an automated laser looks at this sample it may have trouble correctly defining all the cell types. It’s not a mistake per-say. The laser analyzer is an amazing machine and really modernizes veterinary medicine. But in these cases it isn’t as perfectly defined as we wish it to be.
From the 8-23 CBC we see the values you are asking about: MCV, MCH and MCHC . These are descriptions of the red blood cells. The define the red blood cells and tell us many thing about their health.
MCV is mean corpuscle value, simply the size of the red blood cells. Since RBC usually have a very defined size, anything larger or smaller denotes something out of range.
In this case, it makes perfect sense to me. On 8-23 Kingston was highly anemia and the HCT percentage was very low (9.23%.) The number of RBC was also understandably very low, 1.34 or 1,340, 000 red blood cells. The low normal value is 5.5 or 5,500,000 RBC.
As I explained before, when there is reticulocytosis, there will be a lot of “baby blood cells” put into circulation earlier than normal. These cells are larger because they still contain their RNA. In about 3-4 days they drop the RNA (the reticulated pattern inside the cell) and turn into mature (smaller) RBC. So the MCV is high on 8-23 because these immature cells are larger. It simply is indicative that there has been a sudden large increase in regenerative anemia.
And indeed, when we look at the 9-2 CBC we see a normal MCV value (most RBC are normal sized) and we see the number of RBC has gone from 1,340,000 to 3,530,000! That’s nearly 2 million more brand new red blood cells created in a very short time! The marrow has been working very hard to accomplish this!
The next two values are related to the MCV value. MCH is mean corpuscle hemoglobin. Simply, this is the average quality of the hemoglobin inside the RBC. This is the critical part of the RBC, hemoglobin “carries” the oxygen to the body cells. The better the quality of hemoglobin there is the better able it is to carry oxygen to the body cells ! And Kingston is showing this by his more relaxed and comfortable behavior. He simply feels better because his body is getting more oxygen to the body cells.
Finally the MCHC is another reading that describes something about the hemoglobin. Mean corpuscular hemoglobin concentration is the average concentration of hemoglobin in your red blood cells. This particular value may be used to determine the CAUSE of anemia. In some blood disease conditions, the RBC remain “pale” and this indicates not enough quality hemoglobin inside the RBC. If it is low and the RBC are pale then it might indicate iron deficiency. Not too many dogs will have this condition, but those that do are having either a nutritional problem absorbing iron from their food or there is storage and release problem with the liver. There is no need to worry about this high value on the CBC, this number will change very soon.
So in short, when there has been anemia (from any cause) we want a way to evaluate how hard the bone marrow is working to make new red blood cells and we want to know is it making really good red blood cells and in the quantity we need it to?
Because your vet never did a panel that included the reticulocytes, I had to go about figuring this out sideways, deconstructing the RBC values to determine that there must be reticulocytes being manufactured. It is always easier to just look at the reticulocyte value on the CBC to determine if there is regenerative anemia and in what quantity! This is a standard value on an anemia panel.
What Vally is referring to is the bilirubin value, this is a measurement of the amount of destroyed RBC material in the blood. It tells us that red blood cells have been destroyed and the waste is still in the blood. Unfortunately this also means that the kidneys and liver must process this material very quickly to avoid it from staying in the blood. If this doesn’t happen quickly enough you will see a dog become jaundiced, there is a lot of bilirubin (this waste is the brown bile from RBC) in the blood.
I’ve yet to see the chem screen so I have no idea if there is still red blood cell destruction continuing, if there is then you might need the aspirin to prevent an improper clotting cascade. If the hemolysis has stopped you do not need to use aspirin. Your vet says aspirin is contraindicated but in the critical acute stage of hemolysis, a dog can succumb quickly if rapid improper clotting is not controlled in some manner. This is called DIC disseminated intravascular coagulation.
It is always important to see how the prednisone is affecting the liver values (which can become very high), those are critical values on the chem screen also. Some dogs react badly to prednisone and develop a drug induced diabetes, need to see the glucose value. Did your vet offer to show you the chem screens?
Dr. Dodds commonly uses azathioprine in treatment along with cyclosporine, as you noticed when you read her protocol that I pointed out to you on this page:
https://www.secondchanceaihadogs.com/hemopetresources
“In cases where sustained more potent immunosuppression is required for clinical stabilization, azathioprine (Imuran) should be instituted along with cyclosporine. Dose is 1 mg/lb/day for 7-10 days initially followed by a downward tapering over several weeks. Azathioprine may be needed every other day or less often, on a longterm basis. As azathioprine takes about 10 days to effectively suppress T-cells,
clinical responsiveness will not occur immediately. Cyclosporine is therefore given concurrently in the early stages of the disease to provide rapid immunosuppression until the azathioprine takes hold.”
If you have already done the consultation with her she will have mentioned this to you as a possible treatment combination. There is nothing wrong with azathaioprine. It can be implemented alongside cyclosporine if needed. But in this case with Kingston he responded quite nicely to the prednisone and azathioprine combination without having to also use cyclosporine.
To avoid relapse it will be important to wait until he has reached a normal HCT / PCV (which is about 38-45%) and then to carefully reduce the prednisone at a rate of no more than 25-33% dosage per every two weeks. Then evaluate and repeat after another CBC in two weeks etc. The aza can also be decreased very slowly as well. Whether both can be reduced simultaneously is not known yet but I would advise caution doing that to avoid relapse.
These blood conditions are extremely variable from dog to dog and as of yet there isn’t really one single standard protocol that is shared by the entire veterinary community. Each vet and their clinic develops a protocol that they feel they have had success with over time. This is developed from clinical experience. Many vets simply do not receive complex training in hematology in college because across the multiple species they would have to study many different complex standards. Canine hematology is different enough to make it a field that must be carefully studied.
Some clinics very rarely see canine AIHA IMHA or bone marrow failure and when they do they probably begin by review older material. In the past 5-8 years there has been a number of vets finally beginning to follow a similar protocol to the successful protocol that Dr. Dodds developed nearly 20 years ago. It has been a very large learning curve.
In addition, in most cases from years ago the vet declared the cases as not having a defined cause and therefore they were considered primary cause or the immune system just became overactive on it’s own. That, too, has changed in recent years. Now more vets are understanding that in most of these cases there is a definable trigger that may respond to treatment. This is called a secondary cause, one that is mediated by some outside force. Thus the use of the term IMHA immune mediated hemolytic anemia (caused by some outside trigger) is now often replacing AIHA autoimmune hemolytic anemia, primary cause the immune system.
I have no doubt that Kingston had some outside trigger that started this. This most likely was a combination of having surgery with multiple teeth removed simultaneously with being given a multi vaccine booster shot. These two things were the tipping point. The immune system lost “self tolerance.”
A dog this age could have cancer, but right now I am skeptical about that considering how healthy he was prior to the dentistry work.
From now on it would be wise to follow Dr. Dodds minimal vaccine schedule. That is always available on our website directly at the top of the forum on this page:
https://www.secondchanceaihadogs.com/forums/forum/aiha-dog
Look for Dr. Dodds NEW 2016 Minimal Vaccine Schedule
Print this schedule and always carry it with you when you visit the vet. It is designed to ensure that dogs who had a previous autoimmune condition will not suffer a relapse of this. In your case, if this were me, I would never consider any more boosters and might think very carefully about getting a waiver from my vet about the legally required rabies vaccination as well.
Let’s hope we see huge improvements in the days and weeks to come!
my best patrice
Mel,
I think Vally and I both know how you feel, we’ve been there. It is so frustrating and it is especially panicky when you don’t know why everything is happening. We do want to help you understand but time is limited for you to grasp all of this at once.
The most important thing is that you try to make decisions based on facts, not on your emotions. You want to do something “anything” to help and that makes you susceptible to making wrong choices. Please ask us for help when you are making big decisions. Don’t go surfing the internet looking for miracle cures, they don’t exist. We know, we have looked at all of them.
The good thing is that he was healthy before this happened. A healthy dog is better prepared for the treatment protocol than a dog that has been previously ill. You will have to prepare yourself to be a good home nurse and we can help you with that.
Dogs are amazing at their ability to recover. I guarantee you that his body is working hard to get better. I have seen some dogs I thought would never survive, not only recover but return to a normal life.
Right now the immunosuppressive drugs are working but the immune system is on high alert and it takes time for the drugs to work. The transfusions help buy time until they do work. I am not sure about the infection, I need to see the CBC’s and chem screens that were done. If you have some that were from when he was healthy I would also like to see those for comparison.
It is very difficult when we read something a vet has done that we don’t necessarily agree with. The most important thing for an owner is to be able to trust their vet and have a good relationship. We have in the past sometimes recommended that an owner try to find another vet.
In this case, however, right now I would recommend that you get a second opinion from Dr. Dodds. She has saved many of the dog’s lives on this forum, including both Vally ‘s Bingo and my Chance. As a vet she can evaluate your test results and situation and make appropriate recommendations. This is no different than if your child was ill and you got a second opinion. Any qualified vet should be quite comfortable that you would do this.
Go to this page:
https://www.secondchanceaihadogs.com/hemopetresources
Click on the picture that says Owner Consultation.
This will take you to Dr. Dodds website Hemopet.org and you can look over the Owner Consultation form. You can see there are two choices, we always recommend that owners chose the option that allows you to send attachments, so that she has more information to evaluate. Vally always says to put all your paperwork together into one file because otherwise you will only be allowed to upload one thing. Dr. Dodds knows you are upset, so keep your description concise. Tell her exactly how this occurred. I think you will find her extremely sympathetic about your situation.
Once she has looked over you paperwork and descriptions she will email you back with recommendations. If you have questions you can email her back. I think this will give you more professional advice. We can continue to answer your questions.
On the same page you clicked the link to her website you can also click on her treatment protocol: Dr Dodds IMHA Disease and Bone Marrow Failure. You can read how she treats this and compare that with the treatment you are on now. Click on the arrow in the upper right hand corner to open this full in your browser. Then you can save and print it.
On my worst days when Chance was so sick and I had no idea of what to do, I realized that I needed to set aside my grief and emotions and start studying how to help him. This would have been 2007. I have a medical background so I started to study a veterinary hematology textbook. My local vet was very receptive to my questions and then Dr. Dodds started helping. My vets were delighted to work with her. Some vets are not and I suspect your vet may be one of them.
It is important to control your grief and emotions when you are around your boy. He reads you like a book and will think he has done something wrong if you are upset. Be positive and happy with him at all times. Try to enjoy the time you have together so he knows how much you love him. Be with him as much as you can, but understand that right now he doesn’t feel well and may not respond the way you are used to. Allow him that.
my best, patrice
Mel,
This is unfortunate that your vet decided to give a 10 year old dog booster shots that he did not need and then proceed to perform a complex surgery to remove 12 teeth. This is very likely the cause of his sudden hemolytic anemia.
I have seen this a number of times. A vet gives an older dog multiple vaccines, that are not needed, that challenge their immune system and then performs a very stressful surgery at nearly the same time. In addition it is well known that the removal of teeth releases bacteria into the system leading to increased risk of infections. Your poor guy could not handle this overwhelming stress on his immune system.
On this page click on this article:
https://www.secondchanceaihadogs.com/canine-disease-resources
IMMUNE-MEDIATED HEMATOLOGIC DISEASE AND BONE MARROW FAILURE
Here is the abbreviated part of this article where Dr. Dodds discusses IMHA triggers:
“Immune-mediated hematologic disease is being reported with increasing frequency in animals and humans….In many cases a recent stress (e.g. vaccination; drug; chemical or toxic exposure; surgery; hormonal influence; infection; injury) could be identified as a potential triggering event within the previous 30 days.”
Please read on this page by clicking on the picture, it will open in a new tab.
2016 DODDS VACCINATION PROTOCOL FOR DOGS
https://www.secondchanceaihadogs.com/vaccine-resources
As you can see she recommends that after the complete puppy series is complete there should not be any boosters for core vaccines except for the legally required rabies.
This infection is most likely related to the removal of the teeth. In this review, there is a discussion concerning the relationship of bacterial diseases such as chronic abscesses which can overstimulate the immune system and the relationship to recent vaccinations that also overstimulate the immune system reaction. In other words, the tooth abscess bacterial infection combined with the over stimulation of the immune system by vaccines led to the development of IMHA.
http://veterinarycalendar.dvm360.com/controversies-diagnosing-imha-proceedings
“There is ample evidence for infectious agents to be associated with IMHA, causing parasitic (babesiosis, leishmaniasis, ehrlichiosis, anaplasmosis and dirofilariasis), fungal, and BACTERIAL DISEASES (leptospirosis, CHRONIC ABSCESSES, discospondylitis, pyometra, colitis, and pyelonephritis). The relationship between infection and autoimmunity may be explained by molecular mimicry. Furthermore, in limited surveys a seasonality (summer) and a temporal association between vaccination and onset of IMHA have been suggested, but since no specific vaccine has been implicated, it appears likely that vaccines enhance a smoldering immune process. Many dogs with IMHA have severe leukocytosis (with or without left shift) and also considerable serum liver enzyme elevations (prior to prednisone) suggestive of serious inflammatory processes, which may enhance the immune destruction by activating the macrophage system and the thrombotic tendency. ”
What can be done now? I’ll like to see the CBC and chem screen to get a better idea. I think it might have been better if they put him on a targeted antibiotic rather than a broad spectrum, but we are past that point now. You have no choice but to give antibiotics because of this infection and I am concerned about it.
The most important thing is to continue to suppress the immune system at this point and stop the destruction. It’s critical that this process be monitored closely to reduce risks of inappropriate clotting which is called DI C disseminated intravascular coagulation. We often see vets using low dose aspirin or targeted heparin to do this. It is an important discussion to have with the vet.
Vally can help you make up a medication chart to make this easier and perhaps she will suggest a few other things to add to his supplements.
Please keep us up to date on his daily progress. I will be thinking of you often.
my best, patrice
Mel,
I’m sorry to hear about your Beagle.
Vally is correct, when there is active autoimmune hemolysis (destruction ) of red blood cells there is often a drop in HCT / PCV immediately following a transfusion.
It’s frequent to see a high WBC count in the CBC after the diagosis of IMHA. Yes, sometimes there is an infection. But a more common and misunderstood reason is that the bone marrow responds to anemia by substantially increasing the production of reticulocytes ( immature “baby” ) blood cells. These reticulocytes are pushed out into circulation earlier than normal. They are larger than mature RBC and contain RNA from their growth stage. The size and the reticulated appearance inside the cell makes it look pretty much like a WBC. But in a few days they mature and drop their RNA and look like the smaller concave RBCs.
Automated laser analyzers can have a problem identifying this difference. So usually a vet will do a test called differential to see if this is the case. This attempts to distinguish the reticulocytes from WBC.
Another reason for high WBC count is some sort of disease process causing a systemic inflammatory condition. This might be something like pancreatitis or an inflammatory digestive disease like colitis for instance or even allergies, parasites.
Let me reassure you that rarely is it cancer. Vets are too quick to mention this to owners immediately without first doing some important diagnostics. Yes, a few dogs do develop profound leukemia but I just haven’t seen it that often. And there is generally an extraordinarily high value of WBC that is very diagnostic for leukemia. It’s not usually a puzzle that it might be this.
In older male dogs there are other things I think of first such as tumors (hemangiosarcoma of the spleen or heart), or some kind of digestive disorder. Pancreatitis is often seen, as are things like kidney stones plus infection, SIBO small intestine bacterial overgrowth, colitis, or other intestinal conditions. If your beagle has had a lifetime of poor stomach, this could be the cause.
Other environmental triggers can be recent overvaccinations, atopic allergies (called inhaled allergies that results in dermatitis ), bites or stings, bacterial and or viral infections, (leptospirosis comes to mind, or exposure to doggie flu or kennel cough, even parvo depending on his vaccination background. ) Food can be a trigger if you use kibble that contains bacteria, mold etc. Your vet should have done a very extensive history.
You can help us by giving a very detailed look at events from at least a month ago, but anything that sticks out as unusual is important to discuss. I would like to see the last 2 CBC and chem screens if possible, upload them on the Urgent Advice page, only 3 at a time please if they are big files.
What questions do you have for me?
My best Patrice
Nicole,
If you look under the Second Chance Resources menu you will see a variety of pages of resources. Click on Hemopet Resources. On this page you will see “IMMUNE-MEDIATED HEMATOLOGIC DISEASE AND BONE MARROW FAILURE
W. Jean Dodds,” Click on this picture and it will open her article containing her protocol. You can click on the upper right hand arrow to get to a full page you can read, copy, save and print.
On this page she mentions this about cyclosporine’s role in controlling autoimmune disease:
“The goal of this immunosuppressive therapy is to stabilize the ongoing immune destructive process. The dosage guideline we use is adjusted to maintain the absolute lymphocyte count as about 1/3 of the normal range (750-1500/ul).”
These lymphocytes are a value on your CBC complete blood count. Every time you have been getting blood work done, these are on that test. If you look back at your previous CBC’s you can monitor the exact levels of absolute lymphocytes. Your vet can decide where he wants these levels to be for future protection against relapse.
Also go to this page:
https://www.secondchanceaihadogs.com/medication-resources
Click on the Atopica Product insert picture to open that document. Under Dosage and Administration they explain how to dose a dog with allergies in the beginning and how to taper the dose for maintenance. You want to be discussing this tapering with your vet as an appropriate dose, that will probably not be daily, but on certain days of the week. Print the sheet out so you can discuss this with your vet, paper in hand.
I know Maci doesn’t have allergies but the use of cyclosporine for treating IMHA is an accepted “off label” medical use. It is commonly used now in most clinics for this. The reason I want you to look at dosing for maintenance for allergies is to help your vet tweak the doses according to an acceptable dose in general for dogs.
Absolutely. Dogs do survive this. I base this on years of talking with owners on this list and my own careful research into the details of how treatments have become more sophisticated in recent years. Vets pay far more attention to the emergency acute care stage of the condition and that is very valuable. If there is one thing I can advise all owners, get to the vet fast and don’t worry that you don’t understand all that is happening. Most vets do understand these treatments better and keeping a dog alive past the first 48 hours is very critical to having success.
When Chance was diagnosed with bone marrow failure in 2007 there was little to no information to be found. It was dreadful trying to find ANYTHING at all. Now the internet if full of valid research and descriptions of the condition he was suffering. Of course back then, Dr. Dodds knew what this condition was and she had all the information I needed to save his life.
So things have changed significantly and older textbooks and older studies really are outdated and that information should be taken with caution.
Your vet is one of the more forward looking vets who understands the role of lymphocytes (called T-Cell lymphocytes or commonly called Killer T-Cells) in autoimmune conditions.
These particular immune cells are made in the bone marrow, along with all other blood cellular elements. But then they go to the thymus gland to get their instructions about what they are supposed to be destroying (such as cancer cells.) These cells can become “rogue” and misunderstand their instructions, instead attacking and destroying the body’s cells such as red blood cells. This is the most likely cause of most AIHA and IMHA. Only the triggers can be different from one dog to the next.
Of course without T-Cells we can also become very sick because they do perform a very critical job in our body. So we want to maintain enough of them to protect ourselves. When the immune system has trouble figuring out how to protect us, we get into trouble. So if you are following my chain of thought, for the future we don’t want to completely disable Maci’s immune functions, we want to make it a bit less reactive to triggers.
That means for the rest of her life you must be more cautious about what she interacts with, removing most of the stress from her life. By that I mean all kinds of stressors. Visitors in your home, other pets from outside your home, interactions with wild animals, pests like ticks, fleas, mosquito, foods that are novel or contain “non-food-like” ingredients, avoid vaccine boosters (except for legally require rabies), certain medications like antibiotics or flea and tick preparations that are ingested and become systemic. The list is very long and I can’t cover them all here.
Just remember that she has survived but that she is a slightly different dog than the one you went into this disease with. She is more fragile and needs a gentler life. Humans are very good at being compassionate and care for their pets so this is an easy task. If this were me I would never travel anywhere with her and I would never leave her at home for my own trips. I already make all my dog’s food at home so I can control what goes into their bodies. I see my vet regularly for checkups to ensure I am catching anything amiss.
You are doing a great job in learning all you can about this. You are a Great Mom!
What else can I help you with?
my best, patrice
Hope,
Is this a skin infection or internal infection?
Did they mention MRSA, or staphylococcus? These are 2 possible skin infections that can occur during immuno-suppression treatment. Staph usually clears quickly on antibiotics. MRSA is a far more resistant skin infection that doesn’t respond to treatment with certain antibiotics. It can be severe in dogs. If you need more information let me know.
I’m not a fan of using ketoconozole for this treatment. Why is the vet so eager to do this?
Goodluck, thinking about you tonight
Patrice
Please reread Dr. Dodds protocol on the Hemopet Resources page that I posted the link to above. Look for this title
Dr Dodds IMHA Disease and Bone Marrow Failure.
She specifically mentions why she does not recommend Cytoxen. Her protocol is very clear about all the drugs and dosages she recommends.
my best
patrice
Hope,
I’m really sorry to read this. There is nothing more frustrating and frightening than for an owner to be put out of the loop about their dog’s health.
This ketoconazole dosing to lower the dose of cyclosporine protocol has been studied and it was the recommendation from the study to use this as a method to reduce the costs of cyclosporine. The study came to the conclusion that the blood levels of cyclo remained at therapeutic levels.
https://www.ncbi.nlm.nih.gov/pubmed/9449179
But please note they used 5 Beagles that were healthy for this study.
I would never urge an owner to try this method of treatment considering how critical the cyclosporine is to the treatment protocol. Some vets may dose this way and feel confident and I won’t criticize them. Other vets follow more closely their own clinical experiences of success and may not carefully follow recommendations from such a limited study.
But a study with 5 healthy dogs isn’t really a glowing review for me. If I was an owner with a very sick dog I would want to read a study that tested this on hundreds of dogs.
Such a study was done on Atopica when Novartis was looking to market it for treatment of canine atophy (inhaled allergies.) You can find the product insert where the results of these trials are presented in the Medication Resources page. Of course you can read all the negative side effects but for all drug trials there will always be some participants who have these. The degree of the side effects and the percentage of the whole are the critical considerations. Note that this trial was to determine if this drug reduced the allergic reactions of the dogs, it was not to test it for us in treating autoimmune blood diseases. But from this trial we know how dogs react to this medication and what possible side effects there may be, this is good general knowledge that can be applied to its off label use for many autoimmune conditions.
https://www.secondchanceaihadogs.com/medication-resources
The solution is really simple. Put her back on the Atopica brand or a suitable generic and see if this results in an improvement. If this were me I would not continue with the ketoconazole. You may want to temporarily increase the dose of prednisone as well.
Have you thought about doing a consultation with Dr. Dodds? I would highly recommend this as an excellent way to get a second opinion from another veterinarian. You can find the link to the consultation form on this page, second link on the top of the page.
https://www.secondchanceaihadogs.com/hemopetresources
Many of us have used Dr. Dodds as our guardian angel. She saved Chance’s life.
my best, patrice
![bingo-14-5_1200x775](https://www.secondchanceaihadogs.com/wp-content/gallery/aiha-dogs_2/bingo-14-5_1200x775.jpg "Vally\'s Bingo \\"Smile\\"")
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