Acute leukemia with bone or joint symptoms of sufficient magnitude to obscure and delay the correct diagnosis has been reported but is rarely mentioned in the recent literature, particularly in adults. The authors report an adult with rapidly fatal acute leukemia and a clinical course dominated by recurrent osteoarticular symptoms; osteoarticular symptoms preceded the diagnosis of leukemia by 3 months and delayed diagnosis and treatment. The correct diagnosis requires awareness of the osteoarticular manifestations of acute leukemia and examination of blood or bone marrow smear by an experienced observer; a biopsy specimen of bone or joint lesions or examination of cytocentrifuged synovial fluid may aid in diagnosis. The immediate cause of death in our patient was respiratory failure with prominent leukemic interstitial pulmonary infiltrates at autopsy; clinically significant leukemic pulmonary infiltrates have only rarely been reported. The authors review the literature on pulmonary and osteoarticular manifestations caused by acute leukemic infiltrates.