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Pericardial effusion is commonly present in patients with moderate-to-severe hypothyroidism. However, large pericardial effusion causing cardiac tamponade (CT) is extremely rare. We report an atypical presentation of primary hypothyroidism (PH) where a young male presented with CT as the first manifestation of PH. The patient was treated with an immediate pericardiocentesis followed by levothyroxine replacement and showed complete resolution of pericardial effusion on follow-up. Hypothyroidism should be suspected as a possible etiology of massive pericardial effusion/CT in patients who have associated signs and symptoms of hypothyroidism and have bradycardia in the setting of CT.