Fgf signaling plays essential roles in many developmental events. To investigate the roles of Fgf4 signaling in zebrafish development, we generated Fgf4 knockdown embryos by injection with Fgf4 antisense morpholino oligonucleotides. Randomized LR patterning of visceral organs including the liver, pancreas, and heart was observed in the knockdown embryos. Prominent expression of Fgf4 was observed in the posterior notochord and Kupffer's vesicle region in the early stages of segmentation. Lefty1, lefty2, southpaw, and pitx2 are known to play crucial roles in LR patterning of visceral organs. Fgf4 was essential for the expression of lefty1, which is necessary for the asymmetric expression of southpaw and pitx2 in the lateral plate mesoderm, in the posterior notochord, and the expression of lefty2 and lefty1 in the left cardiac field. Fgf8 is also known to be crucial for the formation of Kupffer's vesicle, which is needed for the LR patterning of visceral organs. In contrast, Fgf4 was required for the formation of cilia in Kupffer's vesicle, indicating that the role of Fgf4 in the LR patterning is quite distinct from that of Fgf8. The present findings indicate that Fgf4 plays a unique role in the LR patterning of visceral organs in zebrafish.

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A COVID-19 patient (53-year-old woman from Japan) was admitted to our hospital. She had a high fever (38.3 °C), cough, fatigue, and loss of appetite. She was a smoker and took migraine medication. A thoracic computed tomography (CT) scan showed no evidence of pneumonia. She was treated with antibiotics, protease inhibitors, inhalant corticosteroids, and antivirals. Anti-interleukin-6 receptor antibody tocilizumab (TCZ 400 mg) was added on day 2. On day 4, her temperature decreased, but her vital signs suddenly worsened, with an SpO2 of 70% in ambient air, a blood pressure of 70 mmHg (systolic), loss of consciousness, and tachypnea. Her CT showed bilateral lung consolidation and no pulmonary embolism. She was connected to the ventilator. On day 11, her respiratory condition improved (PaO2/FIO2 400), and she was able to withdraw from the ventilator. Her laboratory data (white cell count, ferritin, d-Dimer, C-reactive protein, and β2-microglobulin) did not increase even at the time of exacerbation, except for Galectin-9 (Gal-9). The plasma Gal-9 levels increased 2.3 times from before the administration of TCZ, followed by a swift decrease associated with improvements in respiratory status. She was discharged on day 16. Patients with TCZ-treated COVID-19 require careful observation.