The objectives of the study were to describe a novel presentation of tetanus and to review the course of the respiratory component and the treatment and management of the disease. A case report is presented with a review of a 25-year experience at Mayo Clinic. We describe the case of a 65-year-old woman who presented with persistent hiccups, dyspnea, and pleurisy of 3 days duration that was caused by tetanus from inadequate secondary immunity. She required intubation for progressive trismus and laryngospasm-associated respiratory failure. Infusion of lorazepam did not control her spasms. Refractory spasms and hiccups resolved with fentanyl and cisatracurium therapy. After 3 weeks, the patient was weaned from the ventilator with complete recovery. In the past 25 years, nine additional patients have presented to Mayo Clinic with acute tetanus. Respiratory failure requiring intubation developed in seven patients, and six of the seven intubated patients survived with minimal deficits. The prognosis of tetanus is favorable if it is diagnosed promptly and if treatment and supportive measures are begun. To our knowledge, this is the first report of a patient with acute tetanus presenting with hiccups. This report also confirms the results of previous studies that suggested a need for improved immunity in the elderly population.