helicobacter cinaedi has come to be recognized as an important organism , especially among immunocompromised patients . h. cinaedi sometimes causes cellulitis but the main symptom is only fever without any focal findings in most cases . furthermore , unlike most other infectious diseases , the clinical course is not acute . for these reasons , when an sle patient becomes febrile , we should determine whether there has been an exacerbation of sle itself or whether the condition is a complication of an infectious disease . this is vital because opposite strategies are used in the treatment of sle and infectious diseases . in the present case , h. cinaedi bacteremia occurred in a patient with sle , who initially only showed fever . these symptoms mimicked a flare of the disease , which led us initiate the bolus administration of methylprednisolone . her symptoms included a typical rash , severe multiple organ failure , consciousness disturbance and retinal vasculitis . a laboratory analysis revealed reduced c3 , c4 and ch50 levels ( 20 mg / dl , 7 mg / dl and 10 u / ml , respectively ) and anti - nuclear antibody positivity ( 640 , homogenous , speckled ) , and anti - dna antibody negativity . she was in a severe condition and was refractory to the initial treatment of prednisolone ( 1 mg / kg / day ) . plasmapheresis , high - dose methylprednisolone ( 1 g bolus for 3 days ) and an increased dose of prednisolone ( 1.3 mg / kg / day ) were necessary to achieve remission from sle . after the initial therapy , her condition remained stable with the administration of prednisolone ( 10 mg / day ) for more than 10 years . a regular blood examination showed a gradual increase in the patient 's c - reactive protein ( crp ) level from 3 months before her admission , which had previously been normal . at first , an exacerbation of sle was suspected and the amount of prednisolone was increased to 15 mg / day . one month before the admission , she suffered from a high grade fever ( 39 ) at night with shivering , chills and mild nausea . a complete blood cell count revealed anemia ( hb , 7.3 g / dl ) with an increase in the number of fragmented red blood cells , leukocytosis ( wbc , 18,880 /l ) with neutrophilia ( 93.5% ) , and severe thrombocytopenia ( platelet count , 37,000 /l ) . tests for anti - nuclear antibodies and anti - dna antibodies were negative and the patient 's complement values were normal ( c3 , 87 mg / dl , c4 , 24 mg / dl , and ch50 , 51 u / ml ) . an interferon- release assay tb was negative and no vegetation was observed by transthoracic echocardiography . 1 ) and the values of alkaline phosphatase and -glutamyltranspeptidase were also elevated ; however , she had no abdominal pain . the patient 's blood cultures being negative , and the focus of infection had not been detected on the fourth day of admission . we were therefore forced to start methylprednisolone ( 1,000 mg / day ) due to suspected acalculous cholecystitis which was thought to have occurred due to a flare of sle or a complication of vasculitis . the next day , the patient 's blood cultures were found to be positive ( after 5 days of incubation ) and microscopy showed gram - negative spiral bacteria ( fig . the isolate was finally identified as h. cinaedi by a pcr and 16s rrna gene sequencing . we considered that the patient 's thrombocytopenia had been caused by h. cinaedi bacteremia , and stopped the bolus administration of methylprednisolone ; prednisolone was reduced to the maintenance dose . with the administration of meropenem , the patient 's temperature decreased and there was an improvement in her laboratory data with regard to her platelet count , crp level , and the number of fragmented red blood cells . the antibiotic was changed and de - escalated to ampicillin , which caused a systemic drug eruption . doripenem was administered for 3 weeks ; thus , the total duration of treatment reached 5 weeks , at which point , the antibiotics were stopped due to pancytopenia . one month after the treatment , the h. cinaedi bacteremia relapsed with a high - grade fever and cellulitis ( fig . meropenem was administered intravenously for another 2 weeks , and 6 weeks of oral minocycline were given , no relapse occurred after this treatment . abdominal ct on admission showing the thickness of the gallbladder wall ( white arrowheads ) . psl : prednisolone , mpsl : methylprednisolone , mepm : meropenem , abpc : ampicillin , ipm / cs : imipenem / cilastatin , azm : azithromycin , drpm : doripenem , wbc : white blood cell ( /l ) , hb : hemoglobin ( g / dl ) , plt : platelet ( 10/l ) , ast : aspartate aminotransferase ( u / l ) , alt : alanine aminotransferase ( u / l ) , alp : alkaline phosphatase ( u / l ) , crp : c - reactive protein ( mg / dl ) , closed triangle : positive blood culture , open triangle : negative blood culture cellulitis complicated with secondary bacteremia was seen on both extremities and the patient s back . h. cinaedi is a gram - negative spiral bacterium that belongs to the helicobacteriaceae family . it is hypothesized that h. cinaedi infection occurs via the oral route . in some reports , the possibility of zoonotic transmission from animal feces to humans has been discussed . however , the patient had no pets and no contact with animals . the median time for h. cinaedi to become positive in blood cultures is 5 days ( 2 - 12 days ) , and the positive ratios from 5 to 7 days were only 55% and 87% , respectively ( 1 ) . in order to successfully detect h. cinaedi bacteremia , at least 7 days of incubation should be necessary , although only 1 - 3 days are sufficient for most other organisms . the other characteristics of h. cinaedi bacteremia are nonspecific symptoms and a tendency of relapse . it has been hypothesized that h. cinaedi infection is associated with cellulitis , arthritis and gastroenteritis ( 2 - 4 ) ; however , fever is the only symptom in many cases . actually , in ten cases of h. cinaedi bacteremia that were observed in our hospital in the eight years from 2007 to 2014 , the only symptom was fever in five cases . the four cases of ten showed skin lesions ; however , these were very mild in all of the cases the appropriate antimicrobial agents and the duration of the treatment for h. cinaedi infection have not been established . although we treated the patient for a sufficient length of time ( 5 weeks ) , she nevertheless relapsed . cinaedi bacteremia cases are usually reported in immunocompromised patients such as those with hiv infection , hematological disorders , malignancies , alcoholism and receiving immunosuppressive therapy ( 5,6 ) . some other infectious diseases have been reported to mimic sle or a flare of sle , human parvovirus b19 , cytomegalovirus , visceral leishmaniasis , which is only in endemic area , and so on ( 7,8 ) . some bacterial infections may mimic a flare of sle , and h. cinaedi might be one of them . however , as far as we are aware , reported cases on h. cinaedi bacteremia with sle are very rare ( 9 ) . we finally diagnosed gallbladder thickening and thrombocytopenia , which were associated with h. cinaedi infection itself , not with a flare of sle . although the association with hepatobiliary diseases and enterohepatic helicobacter species have been mentioned , most cases were caused by h. bilis or h. hepaticus ( 10 ) , and not h. cinaedi or cinaedi , there have been only a few reports on hepatobiliary diseases in animals ( 11 ) and only one report on hepatobiliary diseases in humans . our case might represent a possible presentation of the hepatobiliary infections caused by h. cinaedi in humans . in conclusion , we should be mindful of the presence of h. cinaedi bacteremia , especially when we see febrile immunocompromised patients such as patients with sle . cinaedi takes longer to diagnose , the most popular symptom is only fever and it is sometimes associated with various symptoms . once an h. cinaedi infection is diagnosed , it is necessary to treat the patient with antibiotics for more than one month due to the tendency to relapse .