INTRODUCTION: This is a case of a patient presenting with a cystic lesion on the head of the pancreas, leading to pancreatic malignancy like symptoms, to be found growing oral flora in the aspirate culture. CASE DESCRIPTION/METHODS: A 61-year-old Male with a history of GERD, hiatal hernia presented to the emergency department with epigastric and right upper quadrant abdominal pain associated with nausea. - His pain was on and off in the preceding 1 year, worse in the past 4 months. Pain worsened with eating, and at night. He had an associated 28-pound weight loss since onset of symptoms. Patient was a active cigarette smoker with 1 pack per day since the last 40 years and had poor dentition. - Work-up with a CT scan of the abdomen revealed a thick walled 7.7 × 8.1 × 12 cm cystic mass in the head of pancreas compressing the stomach and duodenum, causing a pseudo meningocele in the posterior lumbar soft tissues and enlarged portocaval and paraaortic lymph nodes. - Laboratory studies revealed a Total bilirubin of 1.25 and a lipase level of 326. CEA and CA 19-9 were not elevated. - Esophago-gastro-duodenoscopy with endoscopic ultrasound were performed for biopsy of the mass. Thick pus was aspirated which was sent for culture. - He underwent absesso-gastrostomy with double pigtail stent into the abscess. - Aspirate from the pancreatic cyst grew oral flora with-Hemophilus Influenzae, Streptococcus (Viridans and Beta-hemolytic), Actinomyces Odontolyticus and Rothia Dentocarioa - Amylase in the fluid was >10,000. Cytology of the fluid showed no malignant cells. - Considering the microbiology of the aspirate, it was thought that the patient had a gastric ulcer with erosion to the pancreas causing the pancreatic abscess and peripancreatic findings. - Follow up CT scan in 2 days showed decompression of the fluid collection. - He was recommended treatment with Augmentin for one year. DISCUSSION: - Pancreatic pseudocysts are extra-pancreatic fluid collections lined with fibrous tissue without an epithelium. - Pancreatic cysts are cystic collections found as incidental findings in 2% of the population. Many pancreatic serous and mucinous neoplasms present as such. - Size of the cyst >3cm, thick and irregular wall, solid components to the cyst are features of likely malignancy. - This is a rare presentation of a patient presenting with malignancy like symptoms, having an infective cyst that when cultured grew oral flora.Figure 1.: Pancreatic cystic structure seen on the CT scan, compressing the stomach.