The purpose of this report is to describe two cases of pericardial effusion with pre-tamponade leading to diagnosis of underlying hypothyroidism. Both patients were women with large longstanding pericardial effusion. The first patient was 47-years-old and the second was 46. Diagnosis of hypothyroidism, whose clinical features were equivocal in the first case case and frank in the second, was confirmed by hormone tests. Treatment consisted of pericardial drainage and hormone replacement therapy with increasing doses. Outcome was favorable in both cases with restoration of euthyroidism. Clinical status was satisfactory in both cases with a follow-up of five months in the first patient and three months in the second. Pericardial effusion with pretamponade is an exceptional complication of prolonged hypothyroidism that should be considered in patients presenting with large longstanding but well tolerated pericardial effusion with no evidence of infection or inflammation.

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