Pancreatic Pseudocyst with Multidrug-Resistant Streptococcus Managed by Cystogastrostomy: A Case Report

Pancreatic pseudocysts are common complications associated with acute or chronic pancreatitis, characterised by a localised accumulation of serosanguinous fluid lacking an epithelial lining. While these collections are often sterile, secondary bacterial infection can occur. Infected pancreatic pseudocysts involving multidrug-resistant (MDR) Gram-positive pathogens like Streptococcus species (spp.) are exceedingly rare and present a significant therapeutic challenge. We present the case of a 54-year-old Asian male who presented with severe epigastric pain and poor glycaemic control (glycated haemoglobin: 8.7%). He had a history of alcohol-induced acute pancreatitis 6 months prior. Abdominal contrast-enhanced computed tomography (CECT) revealed a giant thin-walled fluid collection (106 × 84 mm) with internal debris, consistent with an infected pancreatic pseudocyst. Due to persistent symptoms and inadequate response to conservative medical management, an open cystogastrostomy and pancreatic necrosectomy were performed. Intraoperative fluid cultures yielded a pure growth of Streptococcus spp. Antibiotic susceptibility testing demonstrated a MDR profile, though the isolate remained susceptible to amoxicillin-clavulanic acid. Targeted oral amoxicillin-clavulanic acid therapy for 7 days led to an uneventful recovery. A 45-day follow-up CECT confirmed complete resolution. This report underscores the emergence of atypical MDR Gram-positive pathogens in pancreatic infections within immunocompetent hosts. Even when advanced molecular identification tools are unavailable, standard surgical management combined with strict culture-guided antimicrobial therapy remains effective.