Congenital leukemia is a very rare disorder accounting for less than 1% of all c h i l d h o o d l e u k e m i a s . Tr a n s i e n t
Myeloproliferative Disorder (TMD) occurs in 4 to 10% of infants with Down Syndrome (DS) characterized by numerous circulating blast cells and spontaneous resolution within a few weeks. We present a 3day old male baby with DS presenting with clinical features of shock and  high percentage of blast cells in peripheral smear. This case is presented to highlight the clinical and laboratory diagnostic dilemma.