Introduction: Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy with a multitude of presentations. With appropriate treatment it has an excellent prognosis. We describe this series of patients with ALL to demonstrate the varied manifestations of ALL that presented to a tertiary level pediatric centre. Materials and Methods This descriptive study was conducted in the Pediatric Hematology–Oncology Unit from April 2012 to June 2015. All the patients with ALL were included in the study. Clinical features at presentation, laboratory investigations and outcomes were recorded and analysed. Results 113 patients with ALL were recruited. The predominant symptom bringing the child to medical attention were PUO like presentation in 44%, severe anemia in 61%, bleeding manifestations in 26%, hepatosplenomegaly in upto 94% and arthritis and bony pain in 35%. There was no organomegaly or lymphadenopathy in 11%. Uncommon presentations were CNS manifestations in 1.8%, abdominal distension in 8%. Most common hematologic finding was thrombocytopenia seen in 89%, hyperleucocytosis seen in 17% and normal WBC count in 31%. Blasts in PS were seen in 55%. Conclusion ALL in our study is a male preponderant disease most commonly presenting as a febrile illness and pallor accompanied by lymphadenopathy and/or organomegaly. However atypical manifestations of the illness are common in clinical practice.