Brugia malayi is a roundworm nematode, one of the three causative agents of lymphatic filariasis in humans. Lymphatic filariasis, also known as elephantiasis, is a condition characterized by swelling of the lower limbs. The two other filarial causes of lymphatic filariasis are Wuchereria bancrofti and Brugia timori, which differ from Brugia malayi morphologically, symptomatically, and in geographical extent .
Brugia malayi is transmitted by mosquitoes and is restricted to South and South East Asia. It is one of the tropical diseases targeted for elimination by the year 2020 by the World Health Organization, which has spurred vaccine and drug development, as well as new methods of vector control.
B. malayi microfilaria
History of discovery
Identification of a distinct parasite
Lichentenstein and Brug first recognized Brugia malayi as a distinct pathogen in 1927. They reported the occurrence of a species of human filariae in North Sumatra that was both physiologically and morphologically distinct from the W. bancrofti microfilariae commonly found in Jakarta and named the pathogen Filaria malayi . However, despite epidemiological studies identifying Filaria malayi in India, Sri Lanka, China, North Vietnam, and Malaysia in the 1930s, Lichentenstein and Brug’s hypothesis was not accepted until the 1940s, when Rao and Mapelstone identified two adult worms in India .
Based on the similarities with W. bancrofti, Rao and Mapelstone proposed to call the parasite Wuchereria malayi . In 1960, however, Buckley proposed to divide the old genus Wuchereria, into two genera, Wuchereria and Brugia and renamed Filaria malayi as Brugia malayi. Wuchereria contains W. bancrofti, which so far has only been found to infect humans, and the Brugia genus contains Brugia malayi, which infects humans and animals, as well as other zoonotic species .
Identification of different B. malayi strains
In 1957, two subspecies of human infecting Brugia malayi were discovered by Turner and Edeson in Malaysia based on the observation of different patterns of microfilaria periodicity . Periodicity refers to a pronounced peak in microfilariae count during a 24 hour interval when microfilariae are present and detectable in the circulating blood . The basis for this phenomenon remains largely unknown .
Š Nocturnal periodicity: microfilariae are not detectable in the blood for the majority of the day, but the microfilarial density peaks between midnight and 2 AM nightly.
Š Nocturnal subperiodicity: microfilariae are present in the blood at all times, but appear at greatest density between noon and 8 PM .
Transmission: Vectors and Reservoirs
Brugia malayi is transmitted by a mosquito vector. The principle mosquito vectors include Mansonia, Anopheles, and Aedes mosquitoes . The mosquito serves as a biological vector – it is required for the developmental cycle of the parasite (see Life Cycle) . The geographical distribution of the disease is thus dependent on suitable mosquito breeding habitat.
Š The nocturnal periodic form is transmitted by Mansonia and some Anopheline mosquitoes in open swamps and rice growing areas. These mosquitoes tend to bite at night and appear to only infect humans . Natural animal infections are rare and experimental animals do not retain infection .
Š The nocturnal subperiodic form is transmitted by Mansonia in forest swamps, where mosquitoes bite in the shade at any time. Natural zoonotic infections are common . Cats, dogs, monkeys, slow lorises, civet cats, and hamsters have all been successfully experimentally infected with B. malayi from man and may serve as important reservoirs   .
The accumulation of many infective mosquito bites – several hundreds to thousands - is required to establish infection. This is due to the fact that a competent mosquito usually transmits only a few infective L3 larvae (see Life Cycle), and less than 10% of those larvae progress through all the necessary molting steps and develop into adult worms . Thus those at greatest risk for infection are individuals living in endemic areas – short term tourists are unlikely to develop lymphatic filariasis .
Brugia malayi lifecycle
Development and replication of B. malayi occurs in two discrete phases: in the mosquito vector and in the human. Both stages are essential to the life cycle of the parasite.
Š Mosquito: The mosquito serves as a biological vector and intermediate host – it is required for the developmental cycle and transmission of B. malayi.
4. The mosquito takes a human blood meal and ingests microfilariae (worm-like sheathed eggs) that circulate in the human blood stream.
5-7 In the mosquito, the microfilariae shed sheaths, penetrate the midgut, and migrate to the thoracic muscles were the microfilariae increase in size, molt, and develop into infective larvae (L1 and L3) over a span of 7-21 days. No multiplication or sexual reproduction of microfilariae occurs in the mosquito.
8-1 The infective larvae (L3) migrate to the salivary glands, enter the proboscis and escape onto human skin when the mosquito takes another blood meal. 
Š Human: B. malayi undergoes further development in the human as well as sexual reproduction and egg production.
1-2 The infective larvae (L3) actively penetrate the skin through the bite hole and develop into adults in the lymphatic system over a span of 6 months. Adult worms can survive in the lymphatic system for 5-15 years .
3. The male and female adult worms mate and the females produce an average of 10,000 sheathed eggs (microfilaria) daily . The microfilariae enter the blood stream and exhibit the classic nocturnal periodicity and subperiodicity.
4. Another mosquito takes a blood meal and ingests the microfilariae. Infection depends on the mosquito taking a blood meal during a periodic episode – when microfilariae are present in the bloodstream  .
Adult worms resemble the classic nematode roundworm. Long and threadlike, B. malayi and other nematode possess only longitudinal muscles and move in an S-shape motion . Adults are typically smaller than adult W. bancrofti, though few adults have been isolated. Female adult worms (50 mm) are larger than male worms (25 mm) .
Sections of adult Brugia sp. From a lymph node, stained with hematoxylin and eosin. (L: 200x, R: 400x)
Source: Parasite Image Library, Centers for Disease Control http://www.dpd.cdc.gov/DPDx/HTML/ImageLibrary/Filariasis_il.htm
B. malayi microfilariae are 200-275 um in length and have a round anterior end and a pointed posterior end. The microfilariae are sheathed, which stains heavily with Giemsa. The sheath is actually the egg shell, a thin layer that surrounds the egg shell as the microfilariae circulates in the bloodstream. The microfilariae retain the sheath until it is digested in the mosquito midgut .
B. malayi microfilariae resemble W. bancrofti and Loa loa microfilariae with minor differences that can aid in laboratory diagnosis. B. malayi microfilariae can be distinguished by the noncontinuous row of nuclei found in the tip of the tail. There are two terminal nuclei that are distinctly separated from the other nuclei in the tail, whereas the tail of W. bancrofti contains no nuclei and Loa loa microfilariae nuclei form a continuous row in the tail. B. malayi microfilariae also have a characteristic cephalic space ratio of 2:1  
Posterior end of B. malayi microfilariae – note the two distinctive terminal nuclei
B. malayi is one of the causative agents of lymphatic filariasis, a condition marked by infection and swelling of the lymphatic system. The disease is primarily caused by the presence of worms in the lymphatic vessels and the resulting host response. Signs of infection are typically consistent with those seen in bancroftian filariasis – fever, lymphadenitis, lymphangitis, lymphedema, and secondary bacterial infection - with a few exceptions.
Lymphadenitis, the swelling of the lymph nodes, is a commonly recognized symptom of many diseases. An early manifestation of filariasis, lymphadenitis more frequently occurs in the inguinal area during B. malayi infection and can occur before the worms mature .
Lymphangitis is the inflammation of the lymphatic vessels in response to infection. It occurs early in the course of infection in response to worm development, molting, death, or bacterial and fungal infection. The affected lymphatic vessel becomes distended and tender, and the overlying skin becomes erythemous and hot. Abscess formation and ulceration of the affected lymph node occasionally occurs during B. malayi infection, more readily than in Bancroftian filariasis. Remnants of adult worms can sometimes be found in the ulcer drainage .
Lymphangitis (left) and B. malayi filarial ulcer on medial portion of the thigh
The most obvious sign of infection, elephantiasis, is the enlargement of the limbs. A late complication of infection, elephantiasis is a form of lymphedema and is caused by repeated inflammation of the lymphatic vessels. Repeated inflammatory reactions causes vessel dilation and thickening of the affected lymphatic vessels, which can compromise function. The lymphatic system normally functions to maintain fluid balance between tissues and the blood and serves as an integral part of the immune system. Blockage of these vessels due to inflammatory induced fibrosis, dead worms, or granulomatous reactions can interfere with normal fluid balance, thus leading to swelling in the extremities . Elephantiasis resulting from B. malayi infection typically affects the lower extremities of the legs and arms. Unlike bancroftian filariasis, B. malayi rarely affects genitalia and does not cause funiculitis, orchitis, epididymitis, hydrocele, or chyuria, conditions more readily observed with bancroftian infection .
Elephantiasis in the right arm and right leg of a patient from a remote island in the sea of Korea. Patient had suffered from recurrent swelling for more than 30 years before the onset of elephantiasis.
Source: Tai Soon Yong, Web Atlas of Medical Parasitology, http://atlas.or.kr/atlas/alphabet_view.php?my_codeName=Brugia%20malayi
Secondary bacterial infection
Secondary bacterial infection is common among patients with filariasis. Compromised immune function due to lymphatic damage in addition to lymph node ulcerations and abscesses exposure and impaired circulation due to elephantiasis can cause secondary bacterial or fungal infection. Elephantiasis, in addition to the physical burden of a swollen limb, can be a severely dehabilitating condition given bacterial infection. Part of the WHO’s Strategy to Eliminate Lymphatic Filariasis targets hygiene promotion programs in order to alleviate the suffering of affected individuals (see Prevention Strategies)  .
However, clinical manifestations of infection are variable and depend on several factors, including host immune system, infectious dose, and parasite strain differences. Most infections appear asymptomatic, yet vary from individual to individual. Individuals living in endemic areas with microfilaremia may never present with overt symptoms, whereas in other cases, only a few worms can exacerbate a severe inflammatory response .
The development of the disease in humans, however, is not well understood. Adults typically develop worse symptoms, given the long exposure time required for infection. Infection may occur during childhood, but the disease appears to take many years to manifest. The incubation period for infection ranges from 1 month to 2 years and typically microfilariae appear before overt symptoms. Lymphedema can develop within six months and development of elephantiasis has been reported within a year of infection among refugees, who are more immunologically naive. Men tend to develop worse symptoms than women .
Tender or enlarged inguinal lymph nodes or swelling in the extremities can alert physicians or public health officials to infection. With appropriate laboratory equipment, microscopic examination of differential morphological features of microfilariae in stained blood films can aid diagnosis – in particular the examination of the tail portion, the presence of a sheath, and the size of the cephalic space . Giemsa staining will uniquely stain B. malayi sheath pink . However, blood films can prove difficult given the nocturnal periodicity of some forms of B. malayi.
PCR based assays are highly sensitive and can be used to monitor infections both in the human and the mosquito vector. However, PCR assays are time-consuming, labor intensive and require laboratory equipment. Lymphatic filariasis mainly affects the poor, who live in areas without such resources .
The ICT antigen card test is widely used in the diagnosis of W. bancrofti, but commercial antigens of B. malayi have not been historically widely available. However, new research developments have identified a recombinant antigen (BmR1) that is both specific and sensitive in the detection of IgG4 antibodies against B. malayi and B. timori in ELISA and immunochromatographic rapid dipstick (Brugia Rapid) test. However, it appears that immunoreactivity to this antigen is variable in individuals infected with other filarial nematodes . This research has led to the development of two new rapid immunochromatographic IgG4 cassette tests – WB rapid and panLF rapid – which detect bancroftian filariasis and all three species of lymphatic filariasis, respectively, with high sensitivity and selectivity .
Management and Therapy
The Global Program to Eliminate Lymphatic Filariasis was launched by the World Health Organization in 2000 with two primary goals: 1) to interrupt transmission and 2) to alleviate the suffering of affected individuals. Mass drug treatment programs are the main strategy for interrupting parasite transmission, and morbidity management, focusing on hygiene, improves
the quality of life of infected individuals .
A goal of community base efforts is to eliminate microfilariae from the blood of infected individuals in order to prevent transmission to the mosquito. This is primarily accomplished through the use of drugs. The treatment for B. malayi infection is the same as for bancroftian filariasis. Diethylcarbamazine (DEC) has been used in mass treatment programs in the form of DEC-medicated salt, as an effective microfilaricidal drug in several locations, including India . While DEC tends to cause adverse reactions like immediate fever and weakness, it is not known to cause any long-term adverse drug effects. DEC has been shown to kill both adult worms and microfilariae. In Malaysia, DEC dosages (6 mg/kg weekly for 6 weeks; 6 mg/kg daily for 9 days) reduced microfilariae by 80% for 18-24 months after treatment in the absence of mosquito control . Microfilariae numbers slowly return many months after treatment, thus requiring multiple drug doses over time in order to achieve long-term control. However, it is not known how many years of mass drug administration is required to eliminate transmission. But currently, there have been no confirmed cases of DEC resistance .
Chemical structure of diethylcarbamazine
Distribution of salt fortified with iodine and DEC in endemic areas in Haiti
Single doses of two drugs (albendazole-DEC and albendazole-ivermectin) have been shown to remove 99% of microfilariae for a year after treatment and help to improve elephantiasis during early stages of the disease . Ivermectin does not appear to kill adult worms but serves as a less toxic microfilaricide .
Since the discovery of the importance of Wolbachia in the lifecycle of B. malayi and other nematodes, novel drug efforts have targeted the endobacterium. Tetracyclines, rifampicin, and chloramphenicol have been effective in vitro by interfering with larvae molting and microfilariae development. Tetracyclines have been shown to cause reproductive and embryogenesis abnormalities in the adult worms, resulting in worm sterility. Clinical trials have demonstrated the successful reduction of Wolbachia and microfilariae in onchocerciasis and W. bancrofti infected patients. These antibiotics, while acting through a slightly more indirect route, are promising antifilarial drugs .
Secondary bacterial infection is often observed with lymphatic filariasis. Rigorous hygiene practices, including washing with soap and water daily and disinfecting wounds can help heal infected surfaces, and slow and potentially reverse existing tissue damage. Promoting hygiene is essential for lymphatic filariasis patients given the compromised immune and damaged lymphatic systems and can help prevent suffering and disability  .
There is currently no licensed vaccine to prevent lymphatic filariasis. However, recent research has produced vaccine candidates with good results in experimental animals. A glutathione-S-transferase, a detoxification enzyme in parasites isolated from Setaria cervi, a bovine filarial parasite, reduced B. malayi adult parasite burden by more than 82% 90 days post parasite .
Vector control has been effective in virtually eliminating lymphatic filariasis in some regions, but vector control combined with chemotherapy produces the best results. It is suggested that 11-12 years of effective vector control may eliminate lymphatic filariasis . Successful methods of Brugia malayi vector control include residual house spraying using DDT and insecticide treated bednets. Mansonia larvae attach their breathing tubes to underwater roots and plants in order to survive. While chemical larvicides have only provided partial control, plant removal would prevent vector development, but would have potential adverse effects on the aquatic environment. Lymphatic filariasis vector control is neglected in comparison to the far more established efforts to control malaria and Dengue vectors. Integrated vector control methods should be applied in areas where the same mosquito species is responsible for transmitting multiple pathogens .
B. malayi infects 13 million people in south and southeast Asia and is responsible for nearly 10% of the world’s total cases of lymphatic filariasis  . B. malayi infection is endemic or potentially endemic in 16 countries, where it is most common in southern China and India, but also occurs in Indonesia, Thailand, Vietnam, Malaysia, the Philippines, and South Korea  . The distribution of B. malayi overlaps with W. bancrofti in these regions, but does not coexist with B. timori . Regional foci of endemicity are determined in part by the mosquito vectors (see Transmission).
Global distribution of Brugia malayi is limited to south and southeast Asia
Š The World Health Organization’s Global Programme to Eliminate Lymphatic Filariasis: <http://www.who.int/mediacentre/factsheets/fs102/en/>
Š The Global Alliance to Eliminate Lymphatic Filariasis: http://filariasis.org/
Š Gideon Infectious Diseases Online: <http://web.gideononline.com/web/epidemiology/index.php?disease=10930&country=&view=General>
Š Parasite Image Library, Centers for Disease Control <http://www.dpd.cdc.gov/DPDx/HTML/ImageLibrary/Filariasis_il.htm>
 John, David T., and William A. Petri. Markell and Voge's Medical Parasitology. 9th ed. St. Louis: Saunders Elsevier, 2006.
 Sasa, Manabu. 1979. A review on classification and geographic distribution on brugian filariasis. Joint WPRO/SEARO Working Group on Brugian Filariasis. World Health Organization. http://whqlibdoc.who.int/wpro/-1993/WG_FIL_79.3.pdf
 Shiyung, Liu. 2006. Filaria and plasmodium: distribution of endemic diseases and western plain exploitation in Taiwan. XIV International Economic History Congress, Helsinki 2006, Session 46. http://www.helsinki.fi/iehc2006/papers2/Shiyung.pdf
 Edeson, J.F.B. and T. Wilson. 1964. The epidemiology of filariasis due to Wuchereria Bancrofti and Brugia Malayi. Annual Review Entomology.
 Gideon Infectious Diseases Online. Brugia Malayi. http://web.gideononline.com/web/epidemiology/index.php?disease=10930&country=&view=General
 Fischer, P., Erickson S.M, Fischer K., Fuchs J.F., Rao R.U., Christensen B.M., and Weil G.J. 2007. Persistence of Brugia Malayi DNA in vector and non-vector mosquitoes: implication for xenomonitoring and transmission monitoring of lymphatic filariasis. American Journal of Tropical Medicine Hygiene 76(3). 2007, 502-507.
 Lymphatic Filariasis: Epidemiology and Risk Factors. The Centers for Disease Control and Prevention. http://www.cdc.gov/ncidod/dpd/parasites/lymphaticfilariasis/epidemiology_lymphatic_filar.htm
 Southwick, Frederick S. Infectious Disease: A Clinical Short Course. 2nd ed. McGraw Hill Professional, 2007.
 Decraemer W., Karanastasi E., Brown D., and Backeljau T. Review of the ultrastructure of the nematode body cuticle and its phylogenetic interpretation. Biological Reviews 78. 2003, 465-510.
 Brugia malayi. Web Atlas of Medical Parasitology, http://atlas.or.kr/atlas/alphabet_view.php?my_codeName=Brugia%20malayi
 Bench aids for the diagnosis of filarial infections. Plate 2 – Brugia malayi, Brugia timori. World Health Organization 1997. http://www.dpd.cdc.gov/dpdx/hTML/Frames/DiagnosticProcedures/body_dp_bloodbenchaids.htm
 Cross, John H. "Filarial Nematodes: Lymphatic Filariae Wuchereria Bancrofti and Brugia Malayi." Medical Microbiology. 4th ed. The University of Texas Medical Branch at Galveston, 1996. The National Institutes of Health. 27 Feb. 2009 <http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=mmed.section.4949>.
 Lymphatic filariasis. The World Health Organization <http://www.who.int/mediacentre/factsheets/fs102/en/>
 Noordin R, Itoh M, Kimura E, Rahman R, Ravindran B, Mahmud R, Supali T and M Weerasooriya. Multicentre evaluations of two new rapid IgG4 tests (WB rapid and panLF rapid) for detection of lymphatic filariasis. Filaria Journal 6:9, 2007.
 Noordin R, Aziz R, and Ravindran B. Homologs of the Brugia malayi diagnostic antigen BmR1 are present in other filarial parasites but induce different humoral immune responses. Filaria Journal 3:10, 2004.
 Rao RU. Endosymbiotic Wolbachia of parasitic filarial nematodes as drug targets. The Indian journal of medical research. 122(3), 199-204, 2005.
 Rathaur S, Yadav M, Gupta S, Anandharaman V, and Maryada Venkatarami Reddy. Filarial glutathione-S-transferase: a potential vaccine candidate against lymphatic filariasis. Vaccine 26(32), 4094-4100. 2008.
 Remme J.H.F, Feenstra P., Lever P.R., Medici A., Morel C., Noma M., Ramaiah K.D., Richards F., Seketeli A., Schmunis G., van Brakel W.H., and Anna Vassall. Chapter 22. Tropical diseases targeted for elimination: Chagas disease, lymphatic filariasis, onchocerciasis, and leprosy. Book: Disease Control Priorities in Developing Countries.
 Chang M.S. Operational issues in the control of the vectors of Brugia. Annals of Tropical Medicine & Parasitology 96(2) S71-S76, 2002.