Photopenic areas on bone scintigraphy is a rare presentation of childhood leukemia. This includes the more common acute lymphocytic leukemia as well as the far less common myelomonocytic leukemia. Other causes of photopenia on bone scintigraphy in these patients include relapse with marrow replacement and associated bone necrosis. Methotrexate therapy has also previously been described as showing similar photopenic areas secondary to bone necrosis.