Investigations	Results
Hemogram	Hb = 8 g/dl, TLC = 2,000/cmm, DLC = N32 %, L54 %, bands 2 %, blasts 12 %, platelets = 50,000/cmm
Peripheral smear	Normocytic normochromic RBC with increased rouleaux formation, leucopenia with relative lymphocytosis and blasts, moderate thrombocytopenia
Serum calcium	9.0 mg/dl
Serum uric acid	2.2 mg/dl
Serum LDH	655 U/l
Serum phosphorus	2.8 mg/dl
X-ray thoraco-lumbar spine	Normal study
X ray skull	Multiple punched out lesions (Fig. 1)
Urine Bence Jones protein	Negative
Serum electrophoresis	No M band seen
Serum FLC	Not done
MRI spine	Lesion in dorsal subarachnoid space compressing spinal cord from D4 to D8 level (Fig. 2)
MRI brain	Normal study
CSF study	Neutrophil, 2/cmm; lymphocyte, 16/cmm; cytospin-blasts present
CSF-immunophenotyping	Not done
Bone marrow aspiration	Blasts 92 %, SBB-negative
Bone marrow biopsy	Infiltration by Tdt+ve, CD10+ve, CD3−ve, and CD20−ve blasts suggestive of pre B ALL. Grade I marrow fibrosis present