Table 3.

Pain may present as rheumatological, muscle-skeletal, or neurological. The present study asked survey respondents about pain severity in general. Below, pain is covered with a focus on neurological and also in general, including arthritis, joint, and muscle pain, which tend to present as common symptoms with other frequently occurring symptoms, such as headache and fatigue.

“Neurogenic pain with radiculitis is often the starting symptom in adult patients with tick-borne Lyme neuroborreliosis and in some cases the only clinical manifestation”.	[57]
In all of the 41 patients with neuroborreliosis that were examined, pain presented early and was a prominent symptom.	[58]
In a systematic review, the authors found that arthralgias (joint pain) is “the most common form of pain associated with Lyme arthritis”. Acute nervous system involvement also involves acute pain in Lyme disease. The pain is typically neuropathic, aching, radicular, and can be worse at night.	[57,59]
Lyme arthritis may produce knee pain in up to 60% of cases of Lyme borreliosis in North America.	[59,60]
One to three weeks after a tick bite in human granulocytic anaplasmosis (HGA), patients present with fever, chills, “faintness, or generalized musculoskeletal pain with headaches and myalgia”.	[61]
In a systemic review, and based on 21 studies, exposed patients with LD were more likely to have the following: neck pain, myalgia, and arthralgia. These symptoms overlapped with paresthesia, sleep disorder, poor appetite, and concentration difficulties. Neck pain, myalgia, and arthralgia were the three most common overlapping symptoms among exposed patients in North America and Europe.	[62]
In a case report of a 16-year-old boy in Missouri who presented with fever and myalgia, he was diagnosed with ehrlichiosis.	[63]
Myalgias is commonly reported in cases of tularemia, following an incubation period of 3–5 days, and is accompanied by fever, malaise, and headaches, among other symptoms.	[7]
Lyme radiculoneuritis presents with severe and deep muscle pain, which is often asymmetric and worse at night.	[7]
Myalgia is common in almost every tick-borne disease, including babesiosis, RMSF, tularemia, and ehrlichiosis, according to the American Family Physician.	[64]
Myalgia is a clinical feature associated with the following: Anaplasma phagocytophilum, Ehrlichia chaffeensis, Ehrlichia ewingii, Lyme disease (B. burgdorferi), B. miyamotoi, Powassan virus, and Heartland virus.	[16]
The CDC reports the following diseases associated with pain: Babesiosis–abdominal pain; Borrelia miyamotoi disease–abdominal pain; ehrlichiosis–muscle pain; Lyme disease–migratory pain in tendons, bursae, muscle, and bones; tularemia–abdominal pain, severe throat pain, and pleuritic chest pain.	[27]