《儿童淋巴结肿大临床诊治专家共识（2026）》解读与临床实践再思考

doi:10.12372/jcp.2026.26e0203

摘要/Abstract

摘要：

淋巴结肿大作为儿科最常见的临床体征之一，其病因谱广，鉴别诊断极具挑战性。《儿童淋巴结肿大临床诊治专家共识（2026）》的发布引起我国儿科医师的广泛讨论。本述评旨在对共识中的核心内容进行深度解读与拓展，聚焦临床实践中的难点问题，并就部分未竟的内容展开进一步论述。文章将深入探讨淋巴结肿大定义、影像学检查的精细化解读、“潜在诊断线索”的应用、恶性肿瘤“报警信号”的识别、感染性淋巴结肿大病原谱的变迁与诊治策略等。本文旨在帮助临床医师更好地理解和应用共识，提升儿童淋巴结肿大的诊疗水平。

关键词: 淋巴结肿大, 专家共识, 解读, 鉴别诊断, 临床实践, 儿童

Abstract:

Lymphadenopathy, one of the most common clinical signs in pediatrics, encompasses a broad etiological spectrum, posing significant challenges in differential diagnosis. The release of the Expert consensus on the clinical diagnosis and treatment of lymphadenopathy in children (2026) has sparked extensive discussion among pediatricians across China. This review aims to provide an in-depth interpretation and expansion of the core content of the consensus, focus on the difficult issues in clinical practice, and further discuss some unfinished contents. The article will thoroughly explore the definition of lymphadenopathy, refined interpretation of imaging examinations, application of "potential diagnostic clues", recognition of "alarm signals" for malignancies, and the evolving pathogen spectrum of infectious lymphadenopathy along with corresponding diagnostic and therapeutic strategies. This paper seeks to assist clinicians in better understanding and applying the consensus, thereby enhancing the diagnostic and therapeutic standards for pediatric lymphadenopathy.

Key words: lymphadenopathy, expert consensus, interpretation, differential diagnosis, clinical practice, child

中图分类号:

黄丽素, 李嫣, 杨华珍, 刘瀚旻. 《儿童淋巴结肿大临床诊治专家共识（2026）》解读与临床实践再思考[J]. 临床儿科杂志, 2026, 44(4): 277-282.

HUANG Lisu, LI Yan, YANG Huazhen, LIU Hanmin. Interpretation of the Expert consensus on the clinical diagnosis and treatment of lymphadenopathy in children (2026) and rethinking of clinical practice[J]. Journal of Clinical Pediatrics, 2026, 44(4): 277-282.

图/表 1

表1

淋巴结肿大可能的潜在诊断线索与病因"

潜在诊断线索	可能病因	关键辅助检查
1)急性发热+咽痛+双侧颈淋巴结肿大	病毒感染：EBV、CMV、腺病毒等细菌性咽炎/扁桃体炎：A组链球菌等	血常规（异型淋巴细胞比例)
		EBV IgM/IgG、CMV IgM/IgG
		咽拭子培养+快速链球菌抗原检测
2)淋巴结触痛+局部红肿热痛	化脓性淋巴结炎：金黄色葡萄球菌、链球菌等猫抓病：汉塞巴尔通体(有猫接触史)	超声(脓肿形成)
		血培养 (发热时)、脓液培养+药敏
		猫抓病分子生物学检测，淋巴结活检 (Warthin-Starry染色)
3)发热+盗汗+体重减轻（B症状）	恶性肿瘤：淋巴瘤（霍奇金/非霍奇金）、白血病、转移癌（如神经母细胞瘤）感染：结核病、HIV 自身免疫病：组织细胞坏死性淋巴结炎、川崎病、系统性红斑狼疮、幼年特发性关节炎全身型、Castleman病	血常规+外周血涂片 (有无原始细胞)
		淋巴结活检 (病理+免疫组化) 淋巴结穿刺组织或脓液病原学检测（结核分枝杆菌涂片+培养+分型+药敏，MTB Xpert/RIF等结核分子检测）
		骨髓穿刺+活检
		胸部影像学
		TST/IGRA
		HIV抗体
		ANA、抗dsDNA、铁蛋白、IL-6
4)高热+皮疹+黏膜改变(口唇及眼结膜发红、草莓舌等)	感染：猩红热、EBV、CMV、风疹、麻疹、人类疱疹病毒（HHV-6/7）免疫/血管炎：川崎病、系统性红斑狼疮药物反应：如苯妥英钠、血清病样反应	ESR、CRP
		超声心动图(评估冠状动脉)
		病毒血清学(IgM/IgG)
		详细药物史排查
5)发热+白细胞减少+颈淋巴结压痛	组织细胞性坏死性淋巴结炎：常为自限性系统性红斑狼疮：女性多见	淋巴结活检：组织细胞坏死性淋巴结炎 (凝固性坏死，中性粒细胞缺如，组织细胞及CD8⁺T细胞浸润，CD68⁺)
5)发热+白细胞减少+颈淋巴结压痛	组织细胞性坏死性淋巴结炎：常为自限性系统性红斑狼疮：女性多见	ANA、抗dsDNA、抗Sm抗体、补体 (C3, C4)
6)无痛性进行性肿大淋巴结	淋巴瘤：霍奇金淋巴瘤、非霍奇金淋巴瘤 Rosai-Dorfman病：罕见，双侧颈部巨大无痛淋巴结多见转移癌	淋巴结活检 (病理+免疫组化，金标准)：淋巴瘤细胞学特征；Rosai-Dorfman病 (窦组织细胞增生，S100⁺/CD68⁺，伴emperipolesis现象)
		PET-CT (淋巴瘤分期、评估活性)
		针对原发灶的检查 (怀疑转移癌时)
7)肝脾肿大+血细胞减少 (可伴发热)	恶性血液病：白血病、淋巴瘤（晚期/侵袭性）噬血细胞综合征：继发于感染、肿瘤、风湿病等代谢贮积病：戈谢病、尼曼-匹克病（常有家族史、神经症状）	骨髓穿刺+活检（原始细胞比例、有无噬血现象）
		铁蛋白、可溶性CD25(sIL-2R)、NK细胞活性、三酰甘油、纤维蛋白原
		酶活性检测（如葡糖脑苷脂酶）及基因测序 (怀疑代谢病)
8)溶骨性病变+皮疹（如湿疹样、脂溢性皮炎样）	朗格汉斯细胞组织细胞增生症	病变组织活检(皮肤、骨骼、淋巴结)：CD1a⁺、Langerin (CD207⁺) 细胞
		骨骼X线/CT (穿凿样骨质破坏)
		BRAF V600E基因变异检测
9)多中心淋巴结肿大+IL-6升高	多中心Castleman病：浆细胞型或混合型 HIV相关淋巴增殖性疾病（部分也与HHV-8相关）	淋巴结活检：Castleman病病理分型 (透明血管型、浆细胞型、混合型)
		血清IL-6水平
		HHV-8 PCR(尤其HIV阳性或浆细胞型MCD)
		HIV抗体检测
10)快速增大淋巴结+呼吸窘迫/压迫症状	恶性肿瘤（高度侵袭性）：非霍奇金淋巴瘤（如伯基特）、横纹肌肉瘤等严重感染伴脓肿形成：化脓性淋巴结炎压迫气道	急诊影像学检查：CT/MRI(评估肿块范围、气道压迫情况)
		紧急活检/穿刺±流式细胞术±FISH检测(肿瘤诊断)
		血培养+药敏 (怀疑感染)
		必要时紧急手术探查或气管切开
11)特殊接触史/暴露史(动物接触、昆虫叮咬、疫区旅行史等)	猫抓病（猫、狗抓咬）	针对性血清学检测(IgM/IgG)
	布鲁菌病(牛羊接触史、疫区)	血涂片 (疟原虫、利什曼原虫) 虎红平板凝集试验（RBT）初筛布鲁氏菌病试管凝集试验（SAT）诊断布鲁氏菌病
	弓形虫病(猫粪污染、生肉)	淋巴结活检(特殊染色、病原学检查)
	地方性流行病：如鼠疫、兔热病、利什曼病、丝虫病等 (根据流行区域)	详细流行病学史询问
12)家族史+神经系统症状+淋巴结肿大	代谢贮积病：戈谢病、尼曼-匹克病等	酶活性检测(如β-葡糖脑苷脂酶)
		基因测序
		骨髓检查(可见Gaucher细胞或Niemann-Pick细胞)

表1

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