International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties.Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations. Involvement of the central nervous system (CNS) may result acutely from the disease at the initial diagnosis, and the symptoms range from muscle weakness, paresthesias, and hypoesthesia to fecal and urinary incontinence. Paraplegia is an extremely rare initial presentation of undiagnosed leukemia. Case Report: A 15-year-old girl presented with acute urinary and fecal incontinence, and a day later developed inability to move both lower limbs. There was two weeks preceding history of fever, malaise and lower back pain, no associated history of paresthesias or numbness. Examination of both lower limbs revealed decreased tone and reflexes with bilateral extensor reflexes and power of 0/5. There was a loss of sensation around the perianal region with absent anal tone. Cranial nerve and sensory examination were normal. Both peripheral blood film and bone marrow aspiration cytology stained with Leishman stain were consistent with acute myeloid leukemia (AML) FAB M-4 subtype. Cerebrospinal fluid analysis was negative for malignant cells. Magnetic resonance imaging of the lumbosacral region was obtained; both T1-and T2-weighted sequences showed no signal intensity in the spinal cord, theca and cauda, with normal signal intensity involving the intervertebral disc. Patient was commenced on supportive therapy and induction chemotherapy using daunorubicin 45 mg/m2 days 1-3 and cytosine arabinoside 200 mg daily days 1-7. However, patient succumbed to her disease and passed away 10 days into treatment as a result of respiratory complication. Conclusion: Central nervous system involvement is a rare initial presentation of AML. Absence of abnormality on MRI scan does not rule out spinal cord involvement; consequently late recognition may delay treatment and lead to irreversible neurological complication.