Herpesvirus Infections in KIR2DL2-Positive Multiple Sclerosis Patients: Mechanisms Triggering Autoimmunity

In multiple sclerosis (MS), there is a possible relationship with viral infection, evidenced by clinical evidence of an implication of infectious events with disease onset and/or relapse. The aim of this research is to study how human herpesvirus (HHVs) infections might dysregulate the innate immune system and impact autoimmune responses in MS. We analyzed 100 MS relapsing remitting patients, in the remission phase, 100 healthy controls and 100 subjects with other inflammatory neurological diseases (OIND) (neuro-lupus) for their immune response to HHV infection. We evaluated NK cell response, levels of HHVs DNA, IgG and pro- and anti-inflammatory cytokines. The results demonstrated that the presence of KIR2DL2 expression on NK cells increased the susceptibility of MS patients to HHV infections. We showed an increased susceptibility mainly to EBV and HHV-6 infections in MS patients carrying the KIR2DL2 receptor and HLA-C1 ligand. The highest HHV-6 viral load was observed in MS patients, with an increased percentage of subjects positive for IgG against HHV-6 in KIR2DL2-positive MS and OIND subjects compared to controls. MS and OIND patients showed the highest levels of IL-8, IL-12p70, IL-10 and TNF-alpha in comparison with control subjects. Interestingly, MS and OIND patients showed similar levels of IL-8, while MS patients presented higher IL-12p70, TNF-alpha and IL-10 levels in comparison with OIND patients. We can hypothesize that HHVs’ reactivation, by inducing immune activation via also molecular mimicry, may have the ability to induce autoimmunity and cause tissue damage and consequent MS lesion development.


Introduction
In multiple sclerosis (MS), there is a possible relationship with viral infection, evidenced by clinical evidence of an implication of infectious events with disease onset and/or relapse. The viral infection can directly infect the central nervous system (CNS) and induce an inflammatory response that might result in brain damage. Neurotrophic herpesviruses can enter the CNS evading the host protective immune response, inducing acute cell remitting MS according to Lublin [19]. Disease classification was assessed during sample collection using Kurtzke's Expanded Disability Status Scale (EDSS) [20] (mean value at entry: 2.0 ± 1.0, range from 0.0 to 5.6) (Supplementary Table S1a). At entry, the patients had no signs of acute infections, fever or other symptoms. The patients were not receiving potential disease-modifying therapies (e.g., methylprednisolone or azathioprine, glatiramer acetate or interferon-beta) during the 6 months preceding the study. OIND patients satisfying the 1997 revised American College of Rheumatology Criteria regularly attending the Lupus Clinic of the Rheumatology Unit, Department of Medical Sciences, Sant'Anna Hospital, University of Ferrara, Italy were recruited during the same period [21]. Neuropsychiatric manifestations were assessed in accordance with the 1999 ACR nomenclature and case definitions and diagnoses followed the EULAR recommendations [22]. The attribution of NP events was based on physician judgement and considering ACR 'association' and 'exclusion' factors (i.e., their absence favors attribution to SLE), and as 'SLE-favoring factors' of the Italian Study Group on the NPSLE validated attribution model were also evaluated (Supplementary Table S1b) [23]. None of the female MS patients, OIND and control subjects was pregnant before and during the study.

Genotyping of KIR and HLA
Genomic DNA was extracted from whole blood (QIAamp DNA Blood Mini kit, Hilden, Germany). The Olerup Typing kit (West Chester, PA, USA) was used to genotype KIR and HLA alleles and to quantify HHVs genomes by real-time PCR (Supplementary Table S2) following the manufacturer's procedures.

Viral Load Quantification
Overall, 1, 3, 7 and 14 days post-infection, the cells were harvested and DNA was extracted with the GeneAll ExgeneTM Cell SV kit (GeneAll Biotechnology, Seoul, Korea). Real-time PCR for HHVs was performed (as reported in Supplementary Table S2) following the manufacturer's procedures.

Statistical Analyses
The Hardy-Weinberg equilibrium was assessed by the extended version of Fisher's exact test implemented in Arlequin 3.01. Biological variables were evaluated by Student's t test, Fisher's exact test and a logistic regression analysis by Graph pad software. Significant p values were defined as <0.05. p values were corrected (pc) for multiple comparisons, using the Bonferroni correction.

Microglial Cells-NK Cells Co-Culture during HHVs' Infection
We standardized the protocol to obtain human microglial cells from peripheral blood monocytes. We obtained a sufficient quantity of cells from each sample to carry out the analyses (Figure 1a). The generation of M-MG was confirmed by a morphology evaluation and immune-phenotype characterization for the expression of calcium binding protein Iba1 and substance P, typical characteristics of microglia ( Figure 1a). We performed viral infection on microglial cells, obtaining a good viral load after 14 days after infection for HHV-6A, HHV-6B and EBV, while a lower viral replication was observed for HSV-1 and VZV ( Figure 1b). KIR3DS1/KI3DL1 absent/HLA-Bw4 present 1 2 3 0.62 The KIR and HLA allelic distribution was in the Hardy-Weinberg equilibrium. Patients with MS showed a significantly increased frequency of the activating receptor KIR2DS2 (62% vs. 37%; pc: 4.2 × 10 −3 ) and a reduced frequency of the activating receptor KIR3DS1 (12% vs. 33%; pc: 4.2 × 10 −3 ) in comparison with controls. MS patients had an increased frequency of the inhibitory receptor KIR2DL2 (62% vs. 36%; pc: 3.2 × 10 −3 ). No significant differences were found in the distribution of KIR genotypes (AA or Bx) but there was an increase in the HLA-C1/C2 genotype in MS patients (46% vs. 23%; pc: 5 × 10 −3 ). The combination KIR2DS2/KIR2DL2 present/C1 present was significantly increased in MS patients in comparison with controls (48% vs. 28%; pc: 0.037) while the combination KIR2DS2/KIR2DL2 absent/C1 present was significantly decreased in MS patients (6% vs. 31%; pc: 5.8 × 10 −5 ). The logistic regression analysis showed the combination KIR2DS2/KIR2DL2 present/C1 present strictly correlated with the MS condition (p = 0.03; p = 0.016, respectively). No significant differences were observed between KIR/HLA frequencies in OIND patients in comparison with controls (Table 1).

Microglial Cells-NK Cells Co-Culture during HHVs' Infection
We standardized the protocol to obtain human microglial cells from peripheral blood monocytes. We obtained a sufficient quantity of cells from each sample to carry out the analyses (Figure 1a). The generation of M-MG was confirmed by a morphology evaluation and immune-phenotype characterization for the expression of calcium binding protein Iba1 and substance P, typical characteristics of microglia ( Figure 1a). We performed viral infection on microglial cells, obtaining a good viral load after 14 days after infection for HHV-6A, HHV-6B and EBV, while a lower viral replication was observed for HSV-1 and VZV ( Figure 1b).  On the basis of the results obtained with NK cell activation, we evaluated the viral load in MS patients' microglia cells. We observed that KIR2DL2-negative subjects from the MS population were able to control viral infections, in agreement with the results obtained from the NK cell activation assay (Figure 3a-d). In particular, KIR2DL2-negative NK cells were able to control EBV, HHV-6A and HHV-6B more efficiently than NK cells from control subjects. KIR2DL2-positive MS patients controlled only VZV and HSV-1 infections similar to control subjects (Figure 3h On the basis of the results obtained with NK cell activation, we evaluated the viral load in MS patients' microglia cells. We observed that KIR2DL2-negative subjects from the MS population were able to control viral infections, in agreement with the results obtained from the NK cell activation assay (Figure 3a-d). In particular, KIR2DL2-negative NK cells were able to control EBV, HHV-6A and HHV-6B more efficiently than NK cells from control subjects. KIR2DL2-positive MS patients controlled only VZV and HSV-1 infections similar to control subjects (Figure 3h,i). Interestingly, KIR2DL2-positive OIND patients controlled all the infections apart from EBV infection, similarly to what was observed for NK cell activation (Figure 3j).
When we evaluated the NK cell phenotype from MS patients after the co-culture with microglial-infected cells, we observed a significant increase in KIR2DL2 expression (Figure 4a). The augmented KIR2DL2 expression was more evident in the co-culture with HHV-6A, HHV-6B and EBV-infected microglia cells (Figure 4a). These data are in accordance with the results obtained with viral load quantification and NK cell activation status, supporting the role of KIR2DL2 in controlling NK cell activation in the presence of HHV infections. We evaluated the possible impact of KIR2DL2 expression on clinical status in MS patients. We observed that the subjects that respond with a greater increase of KIR2DL2 expression in the presence of an HHV infection were characterized by a higher EDSS (Figure 4b), supporting an involvement also in disease status. Similarly, the subjects that respond with a greater increase of KIR2DL2 expression in the presence of an HHV infection were characterized by a higher frequency of MRI disease activity (Figure 4c). When we evaluated the NK cell phenotype from MS patients after the co-culture with microglial-infected cells, we observed a significant increase in KIR2DL2 expression (Figure 4a). The augmented KIR2DL2 expression was more evident in the co-culture with HHV-6A, HHV-6B and EBV-infected microglia cells (Figure 4a). These data are in accordance with the results obtained with viral load quantification and NK cell activation status, supporting the role of KIR2DL2 in controlling NK cell activation in the presence of HHV infections. We evaluated the possible impact of KIR2DL2 expression on clinical status in MS patients. We observed that the subjects that respond with a greater increase of KIR2DL2 expression in the presence of an HHV infection were characterized by a higher EDSS (Figure 4b), supporting an involvement also in disease status. Similarly, the subjects that respond with a greater increase of KIR2DL2 expression in the presence of an HHV infection were characterized by a higher frequency of MRI disease activity (Figure 4c).   The data are presented as mean ± SE.

Levels of HHVs' DNA in Peripheral Blood
The three populations were analyzed for the presence of viral DNA (HSV-1, VZV, EBV, HHV-6) in peripheral blood. The presence of the EBV genome was observed in 10% of healthy controls, 16% of subjects with MS and in 39% of OIND subjects, with a significant difference between MS patients and OIND patients (p = 0.0004; Fisher exact test) and OIND patients and controls (p < 0.0001; Fisher exact test). Similarly, analyzing the viral load, OIND patients had a higher number of viral genome copies/mL of blood than MS patients (p < 0.0001; Student's t test) and controls (p = 0.0007; Student's t test) (Figure 5a).

Levels of HHVs' DNA in Peripheral Blood
The three populations were analyzed for the presence of viral DNA (HSV-1, VZV, EBV, HHV-6) in peripheral blood. The presence of the EBV genome was observed in 10% of healthy controls, 16% of subjects with MS and in 39% of OIND subjects, with a significant difference between MS patients and OIND patients (p = 0.0004; Fisher exact test) and OIND patients and controls (p < 0.0001; Fisher exact test). Similarly, analyzing the viral load, OIND patients had a higher number of viral genome copies/mL of blood than MS patients (p < 0.0001; Student's t test) and controls (p = 0.0007; Student's t test) (Figure 5a). was reported in KIR2DL2-positive subjects for (f) EBV, (g) HHV-6, (h) VZV and (i) HSV-1. Viral load in KIR2DL2-negative OIND patients for (e) EBV. Viral load in KIR2DL2-positive OIND patients for (j) EBV. NK CTR: NK cells from control subjects; NK MS: NK cells from MS patients. The data are presented as mean ± SE.

Levels of HHVs' DNA in Peripheral Blood
The three populations were analyzed for the presence of viral DNA (HSV-1, VZV, EBV, HHV-6) in peripheral blood. The presence of the EBV genome was observed in 10% of healthy controls, 16% of subjects with MS and in 39% of OIND subjects, with a significant difference between MS patients and OIND patients (p = 0.0004; Fisher exact test) and OIND patients and controls (p < 0.0001; Fisher exact test). Similarly, analyzing the viral load, OIND patients had a higher number of viral genome copies/mL of blood than MS patients (p < 0.0001; Student's t test) and controls (p = 0.0007; Student's t test) (Figure 5a). Overall, 10% of controls, 31% of MS patients and 14.6% of OIND patients were positive for the presence of the HHV-6 genome (Figure 5b), with the highest viral load in MS patients in comparison with controls (p = 0.001; Student's t test) and OIND patients (p < Overall, 10% of controls, 31% of MS patients and 14.6% of OIND patients were positive for the presence of the HHV-6 genome (Figure 5b), with the highest viral load in MS patients in comparison with controls (p = 0.001; Student's t test) and OIND patients (p < 0.0001; Student's t test). Subjects who tested positive for the presence of the HHV-6 genome in Q-PCR were then characterized for the type of virus, HHV-6A or HHV-6B. The subjects positive for the HHV-6A genome were 60% of MS patients and 30% of OIND patients (p < 0.0001; Student's t test), while no control subject was positive for the HHV-6A genome. The subjects positive for the HHV-6B genome were 20% of MS patients, 45% of OIND patients (p = 0.0002; Student's t test) and 100% of control subjects (vs. MS and OIND p < 0.0001; Student's t test). The subjects positive for HHV-6A/-6B genomes were 20% of MS patients, 25% of OIND patients (p = 0.5; Student's t test), while no control subject was positive for HHV-6A/-6B genomes. No samples tested positive for the presence of HSV-1 or VZV DNA as was expected as the site of latency of both these viruses was not the peripheral blood but in ganglion cells. No differences were observed subdividing the samples on the basis of KIR2DL2 positivity (data not shown).

Levels of Antibodies towards HHVs
We evaluated the levels of antibodies (IgM and IgG) towards HHVs (HSV-1, HSV-2; EBV; HHV-6; VZV) in the plasma samples of the three cohorts.
The results obtained by the analysis of EBV EBNA1 IgG evidenced that 75% of MS patients were positive, in comparison with 40% of OIND patients (p < 0.0001; Fisher exact test) and 30% of control subjects (p < 0.0001; Fisher exact test). By dividing the samples on the presence of the KIR2DL2 receptor, 90% of MS patients were positive for EBV EBNA1 IgG in comparison with 49% of OIND patients (p < 0.0001; Fisher exact test) and the 50% of control subjects (p < 0.0001; Fisher exact test). The results obtained with EBV VCA IgG were comparable to EBNA1 IgG results.
The results obtained from the VZV IgG analysis showed that 90% of MS and OIND patients and 80% of control subjects were positive for VZV IgG. By dividing the samples according to the presence of the KIR2DL2 receptor, a slight increase in the subjects positive for VZV IgG was observed in OIND subjects (50%) compared to control subjects (35%) (p = 0.05; Fisher exact test).
The results obtained from the IgG analysis for HHV-6 showed that 100% of MS patients, 95% of OIND patients and 100% of control subjects were positive for HHV-6 IgG. By dividing the samples on the basis of the presence of the KIR2DL2 receptor, a higher percentage of MS (60%) and OIND (60%) patients tested positive for HHV-6 IgG in comparison with control subjects (40%) (p = 0.007, Fisher exact test).
The results obtained from the IgG analysis for HSV-1 showed that 60% of MS patients and 70% of control subjects were positive in comparison with 35% of OIND patients (p = 0.007; Fisher exact test). By dividing the samples on the basis of the presence of the KIR2DL2 receptor, a higher percentage of the subjects positive for IgG against HSV-1 was observed in MS patients (60%) and control subjects (65%) in comparison with OIND patients (p = 0.0007; Fisher exact test).
These results showed that the expression of the KIR2DL2 receptor seems to correlate with the increased positivity for anti-EBV, anti-HHV-6 and anti-HSV-1 IgG; we assessed the levels of positivity for EBV, HHV-6 and HSV-1 IgG in the three populations. We performed serial two-fold dilutions of controls and test samples (initial dilution 1:20 v/v) in dilution buffer (PBS containing 1% skimmed milk). We observed that OIND patients showed the highest titers for EBNA-1 IgG (Figure 6a), while MS patients presented the highest levels for anti-HHV-6 IgG (Figure 6b). The control subjects presented the highest levels for anti-HSV-1 IgG (Figure 6c).

Levels of Inflammatory Cytokines in Plasma Samples
In order to assess the inflammatory state of the subjects, the plasma levels of nine proor anti-inflammatory cytokines (IL-1alpha, IL-1beta, INF-gamma, IL-10, IL-4, IL-6, IL-8, IL-12 and TNF-alpha) were evaluated. They were selected as representative of a different immune response and previously implicated in both MS and neuro-lupus diseases [28,29].
MS and OIND patients showed the highest levels of IL-8, IL-12p70, IL-10 and TNFalpha in comparison with control subjects (Figure 7; p <0.0001; Student's t test). Interestingly, MS and OIND patients showed similar levels of IL-8 (p = 0.36; Student's t test), while MS patients presented higher IL-12p70, TNF-alpha and IL-10 levels in comparison with OIND patients (p < 0.0001; Student's t test). No differences were observed when subdividing the samples on the basis of KIR2DL2 positivity (data not shown).

Levels of Inflammatory Cytokines in Plasma Samples
In order to assess the inflammatory state of the subjects, the plasma levels of nine pro-or anti-inflammatory cytokines (IL-1alpha, IL-1beta, INF-gamma, IL-10, IL-4, IL-6, IL-8, IL-12 and TNF-alpha) were evaluated. They were selected as representative of a different immune response and previously implicated in both MS and neuro-lupus diseases [28,29].
MS and OIND patients showed the highest levels of IL-8, IL-12p70, IL-10 and TNFalpha in comparison with control subjects (Figure 7; p <0.0001; Student's t test). Interestingly, MS and OIND patients showed similar levels of IL-8 (p = 0.36; Student's t test), while MS patients presented higher IL-12p70, TNF-alpha and IL-10 levels in comparison with OIND patients (p < 0.0001; Student's t test). No differences were observed when subdividing the samples on the basis of KIR2DL2 positivity (data not shown).

Discussion
The results of this study demonstrated that KIR2DL2 expression on NK cells gives MS patients a higher susceptibility to HHV infection, confirming our previous results on HSV-1 [14][15][16]. In particular, KIR2DL2 expression on NK cells reduced NK cell activation and consequently HHVs' clearance in microglia cells from MS patients. Interestingly, the co-culture of NK cells with HHV-infected microglia cells induced a significant increase in KIR2DL2 expression on CD16+CD56+ NK cells. When we evaluated the control subjects we observed no statistical differences in the activation status of NK cells between KIR2DL2-positive and negative subjects. Interestingly, previous results showed a correlation between KIR2DL2 and the recurrence of HHV infection in healthy subjects [17]. The authors recognized receptor/ligand pair KIR2DL2/HLA-C1 as a predisposing

Levels of Inflammatory Cytokines in Plasma Samples
In order to assess the inflammatory state of the subjects, the plasma levels of nine pro-or anti-inflammatory cytokines (IL-1alpha, IL-1beta, INF-gamma, IL-10, IL-4, IL-6, IL-8, IL-12 and TNF-alpha) were evaluated. They were selected as representative of a different immune response and previously implicated in both MS and neuro-lupus diseases [28,29].
MS and OIND patients showed the highest levels of IL-8, IL-12p70, IL-10 and TNFalpha in comparison with control subjects (Figure 7; p <0.0001; Student's t test). Interestingly, MS and OIND patients showed similar levels of IL-8 (p = 0.36; Student's t test), while MS patients presented higher IL-12p70, TNF-alpha and IL-10 levels in comparison with OIND patients (p < 0.0001; Student's t test). No differences were observed when subdividing the samples on the basis of KIR2DL2 positivity (data not shown).

Discussion
The results of this study demonstrated that KIR2DL2 expression on NK cells gives MS patients a higher susceptibility to HHV infection, confirming our previous results on HSV-1 [14][15][16]. In particular, KIR2DL2 expression on NK cells reduced NK cell activation and consequently HHVs' clearance in microglia cells from MS patients. Interestingly, the co-culture of NK cells with HHV-infected microglia cells induced a significant increase in KIR2DL2 expression on CD16+CD56+ NK cells. When we evaluated the control subjects we observed no statistical differences in the activation status of NK cells between KIR2DL2-positive and negative subjects. Interestingly, previous results showed a correlation between KIR2DL2 and the recurrence of HHV infection in healthy subjects [17]. The authors recognized receptor/ligand pair KIR2DL2/HLA-C1 as a predisposing

Discussion
The results of this study demonstrated that KIR2DL2 expression on NK cells gives MS patients a higher susceptibility to HHV infection, confirming our previous results on HSV-1 [14][15][16]. In particular, KIR2DL2 expression on NK cells reduced NK cell activation and consequently HHVs' clearance in microglia cells from MS patients. Interestingly, the co-culture of NK cells with HHV-infected microglia cells induced a significant increase in KIR2DL2 expression on CD16+CD56+ NK cells. When we evaluated the control subjects we observed no statistical differences in the activation status of NK cells between KIR2DL2positive and negative subjects. Interestingly, previous results showed a correlation between KIR2DL2 and the recurrence of HHV infection in healthy subjects [17]. The authors recognized receptor/ligand pair KIR2DL2/HLA-C1 as a predisposing factor for HSV-1 infection and reactivation. These results suggest the implication of KIR2DL2 in HHV infection susceptibility in the human population, that has a deep effect on NK cell activation in MS patients. In particular, we observed that the subjects that respond with a greater increase in KIR2DL2 expression in the presence of an HHV infection were characterized by a higher EDSS, supporting an involvement also in disease status. Similarly, the subjects that responded with a greater increase in KIR2DL2 expression in the presence of an HHV infection were characterized by a higher frequency of MRI disease activity.
We showed an increased susceptibility mainly to EBV and HHV-6 infections in MS patients carrying the KIR2DL2 receptor and HLA-C1 ligand. We can hypothesize that HHV-6 and EBV reactivation, by inducing immune activation via molecular mimicry, may have the ability to induce autoimmunity and cause tissue damage and consequent MS lesion development. HHV-6 and EBV infections are common and have a worldwide distribution, and like most herpesviruses they are a ubiquitous infectious agent, infecting greater than 90% of the world's population [30,31]. The association between MS and HHV-6 is supported by its ability to productively infect glial cells [32][33][34]; the persistence of HHV-6 DNA for months in the brain [34]; and the high neuropathogenicity of HHV-6 in a marmoset model [35].
As a proof of concept of the increased susceptibility, we evaluated the levels of HHVs' DNAs. In total, 31% of MS patients, 14.6% of OIND patients and 10% of controls were positive for the presence of the HHV-6 genome, with the highest viral load in MS patients. MS patients presented mainly HHV-6A infection or HHV-6A/-6B co-infection, while OIND patients and controls presented mainly HHV-6B infection. The three cohorts were also evaluated for anti-HHVs IgG. The results obtained by the analysis of EBV EBNA1 IgG evidenced that MS patients presented a higher percentage of positive subjects, mainly in the KIR2DL2-positive group. The results obtained from the IgG analysis for HHV-6 showed a higher percentage of subjects positive for IgG against HHV-6 in KIR2DL2-positive MS and OIND subjects compared to controls. The VZV IgG and HSV-1 IgG analysis showed that MS and OIND patients had the highest percentage of positive subjects, mainly in the KIR2DL2-positive subjects. The increase in only HHV-6 viral load, with the high levels of both EBV and HHV-6 IgG levels in MS patients, sustained a possible increased reactivation of these two viruses in MS patients with low levels of replication but the ability to induce humoral response. This reactivation might result without evident clinical sequelae, but it is able to modify the immune cell status. To evaluate this point, we analyzed the levels of pro-and anti-inflammatory cytokines in serum samples. We observed the highest levels of pro-inflammatory cytokines in MS and OIND [28,29]. In particular, TNF-alpha, IL-8 and IL-12p70 were higher in both MS and OIND patients in comparison with control subjects. These results confirm the enhanced inflammatory status in MS and OIND patients, characterized by an increased cytokine production. Interestingly, there was also an increase in IL-10 levels in MS and OIND patients in comparison with controls, suggesting a role in counteracting the inflammatory envionment in MS and OIND patients.
In fact, EBV reactivation appears to be linked to disease activity in early MS and it has been reported that EBV reactivation in the CNS may play an important role in MS immunopathology [36]. EBNA2 variants have been identified as biomarkers of MS disease course and therapy response [37]. The evaluation of EBV-infected B cells in post-mortem brains of MS cases still provides controversial results [38,39]. However, the efficacy of B cell depleting therapies in relapsing remitting and progressive MS and the pilot trial with in vitro expanded autologous EBV-specific T cell therapy could be considered an indirect evidence of EBV implication in MS, since memory B cells are the target of latent EBV infection [40,41]. Concerning HHV-6, a higher frequency of active infection seems to be related to MS onset [42,43]. In addition, MS plaques showed an increased frequency of HHV-6 DNA and proteins when compared with control tissues [44] and the serum of MS patients presented higher anti-HHV-6 antibody titers than in healthy controls [45]. The possibility to give a complete characterization of NK cell response in each MS patient might help in increasing the safety of therapies with biological and immune-suppressive drugs (e.g., Fingolimod, Natalizumab), that could reactivate HHV infection [46]. Further analyses are needed to confirm these results in a multicentric study, increasing the number of subjects to be enrolled.

Conclusions
Our results demonstrated that the presence of KIR2DL2 expression on NK cells increased the susceptibility of MS patients to HHV infections. We showed an increased susceptibility mainly to EBV and HHV-6 infections in MS patients carrying the KIR2DL2 receptor and HLA-C1 ligand. The highest HHV-6 viral load was observed in MS patients, with an increased percentage of the subjects positive for IgG against HHV-6 in KIR2DL2positive MS and OIND subjects compared to controls. MS and OIND patients showed the highest levels of IL-8, IL-12p70, IL-10 and TNF-alpha in comparison with control subjects. Interestingly, MS and OIND patients showed similar levels of IL-8, while MS patients presented higher IL-12p70, TNF-alpha and IL-10 levels in comparison with OIND patients. We can hypothesize that HHVs' reactivation, by inducing immune activation via molecular mimicry, may have the ability to induce autoimmunity and cause tissue damage and consequent MS lesion development.
The availability of Lirilumab (IPH2102/BMS-986015) [47], a human monoclonal antibody that blocks the interaction of the KIR2DL2 receptor and its ligands, with an ongoing randomized Phase II trial in tumors, could allow a therapeutic approach to promote NK cell activation towards HHV infection in MS patients with a possible rebound in disease outcome. Nevertheless, futher studies are needed to confirm whether these approaches may help in MS clinical management.
Supplementary Materials: The following supporting information can be downloaded at https:// www.mdpi.com/article/10.3390/microorganisms10030494/s1: Table S1a: Demographic and clinical characteristics of MS patients; Table S1b: Demographic and clinical characteristics of SLE patients with neuropsychiatric involvement; Table S1c: Clinical hematology results; Table S2: Real-time PCR primers for HHVs' genome quantitation. Figure S1: Representative staining of monocyte cells obtained from peripheral blood to produce microglia cells.

Institutional Review Board Statement:
The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee Area Vasta Emilia Centro with the number: 01052016).

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data presented in this study are all available upon request.