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Primary pericardial mesothelioma is an extremely rare form of cancer, comprising only 0.7% of all malignant mesotheliomas diagnosed. The case report discusses a 38-year-old male who presented with dyspnea and was initially misdiagnosed with massive tuberculous pericardial effusion. Following pericardiocentesis and surgery, cytological and histopathological analysis confirmed the diagnosis of malignant pericardial mesothelioma. The report emphasizes the importance of cytological examination in diagnosing this rare entity and highlights the poor prognosis, with fewer than 50% of patients surviving beyond six months.