Diarrheagenic E coli Increases Risk for Reactive Arthritis and Musculoskeletal Symptoms Among Travelers

Escherichia coli bacteria
Researchers evaluated the association between diarrheagenic E coli and development of reactive arthritis and musculoskeletal symptoms among international travelers.

Acquiring diarrhoeagenic Escherichia coli (E coli; DEC) increases the risk of developing reactive arthritis and musculoskeletal symptoms among individuals who travel internationally, according to study findings published in Annals of the Rheumatic Diseases.

Of a total of 526 study participants, data were analyzed from the 224 who provided pretravel and posttravel stool samples and completed pretravel, posttravel, and 3-week follow-up questionnaires. Stool samples were analyzed using a multiplex quantitative polymerase chain reaction assay to detect 9 bacterial pathogens, including DEC strains (enteroaggregative E coli, enteropathogenic E coli, enterotoxigenic E coli, enterohemorrhagic E coli, and enteroinvasive E coli), Salmonella, Shigella, Campylobacter, Yersinia, and Vibrio cholerae). Study findings were classified into 4 categories: no pathogens, only DEC pathogens, only non-DEC pathogens, and DEC plus non-DEC pathogens. Participants reported any new posttravel musculoskeletal symptoms through comprehensive phone interviews, which were clinically confirmed by a rheumatologist, if needed. Multivariate analysis was used to identify factors associated with musculoskeletal symptoms such as age, sex, pathogen category, severity of diarrhea, and antibiotic use.

In the posttravel stool findings, DEC-only pathogens were identified in 151 participants (67.4%), non-DEC pathogens in 5 participants (2.2%), DEC plus non-DEC pathogens in 17 participants (7.6%), and no pathogens in 51 participants (22.8%). Of the 224 participants, 38 (17.0%) reported musculoskeletal symptoms in the follow-up questionnaire, of whom 31 (20.5%) were classified with only DEC. In multivariate analysis, DEC-only acquisition was associated with reactive musculoskeletal symptoms (adjusted odds ratio, 3.9; 95% CI, 1.2-13.3); however, no association was observed for age, sex, antibiotic use, or severity of travelers’ diarrhea. Nine participants in the DEC-only group who reported reactive musculoskeletal symptoms met the criteria for reactive arthritis (n=4), reactive tendinitis (n=2), and reactive arthralgia (n=3); most cases were mild. No association was found between the development of reactive musculoskeletal symptoms and antibiotics used to treat travelers’ diarrhea.

Related Articles

Study limitations included the fact that stool samples could not be collected while the study participants were abroad as a result of which some cases of the primary travelers’ diarrhea pathogen may have disappeared before sampling; the data may have overestimated the incidence of musculoskeletal symptoms; and the period between pathogen acquisition and clinical examination was relatively long so if symptoms appeared later than 3 weeks posttravel, it is possible that some cases of reactive arthritis may have been missed.

According to the researchers, acquisition of DEC was associated with an increased risk of developing reactive musculoskeletal symptoms; however, the incidence of travel-related reactive arthritis remained low and was mostly mild.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Tuompo R, Lääveri T, Hannu T, et al. Reactive arthritis and other musculoskeletal symptoms associated with acquisition of diarrhoeagenic Escherichia coli (DEC) [published online March 16, 2020]. Ann Rheum Dis. doi:10.1136/annrheumdis-2019-216736