We present the case of a male child, 10 years old, admitted to Shanghai Renji Hospital on 11 July 2020 because of “recurrent wheezing for 8 years,” with the diagnosis of allergic asthma, allergic rhinitis, food allergy, ADHD (combined type), and intellectual disability. Written informed consent was obtained from the patient.

The child was gravida 2 para 1, full term, delivered by Cesarean section, with no history of choking resuscitation, mixed feeding, and immunizations on time. The child had a history of recurrent eczema (disappeared at 1.5 years), was talking at 2 years, and had rhinitis at 3 years.

At 8 years, the child was diagnosed with intellectual disability and combined ADHD and was treated with methylphenidate hydrochloride, but the symptoms of ADHD were not effectively controlled. The patient did not undergo cognitive behavioral therapy (CBT). Eventually, the child discontinued the drug on his own and was not taking any ADHD medications upon admission.

The patient had a family history of allergic diseases (both parents and sister are allergic). Wheezing first manifested at the age of 1.5 years. The child suffered from recurrent respiratory infections from birth to 2 years of age. Wheezing occurred over six times/year after the age of 3 and was induced by cold air, exercise, rainy weather, and emotional changes. Cough was dry, occurred in the absence of respiratory infection, was induced by cold air, and predominantly occurred at night. There was no evidence of fever, foreign body aspiration, hoarseness, chest tightness, sighing, acid reflux, belching, early satiety, night sweats, lethargy, hemoptysis, and nocturnal sleep snoring during the entire course of the illness. Asthma was accompanied by food allergies to eggs and fish (rash, itching, and cough after eating) and to azithromycin.

A physical examination revealed the following characteristics of the patient: height, 130 cm; weight, 30 kg; hyperactive; the nasal mucosa was slightly pale with edema; and a small amount of clear mucus; double-lung auscultation respiratory sounds were thick with mild wheezing and no wet rales. Heart, abdomen, and nervous systems were normal.

The blood routine detected the following: eosinophils (EOSs), 5.6%; total immunoglobulin E (IgE), 3,380 (IU/mL); household dust mite immunoglobulin E (IgE), 19.3 IU/mL; and mixed mold IgE, 24.3 IU/mL.

Pulmonary function tests and chest computed tomography (CT) detected no abnormalities.

At 8 years of age, the patient underwent treatment with a nebulizer containing budesonide suspension for inhalation, two times a day for 2 months, but discontinued the medication on his own after improvement. At 9.5 years of age, the patient had a severe asthmatic attack with progressive restriction of movement and recurrent episodes of wheezing. At the age of 10, treatment with inhaled corticosteroid (ICS)/long-acting beta agonist (LABA) was initiated: ICS (ticlosone; 100 mg) and LABA (salmeterol; 50 mg) inhalations. However, due to the long duration of asthma and poor ICS–LABA administration control, the treatment was not effective in controlling the symptoms. Oral leukotriene receptor antagonist (LTRA) montelukast sodium (one sachet, once a day) was added, but the patient reported a state of euphoria throughout the day, which resolved after ICS–LABA–LTRA treatment was discontinued.

After the diagnosis upon admission, the following treatment was initiated, as shown in Figure 1: a child received initial treatment with ICS (ticlosone; 100 mg) + LABA (salmeterol; 50 mg) + omalizumab (150 mg). ICS + LABA was initially used in the morning and evening, one inhalation per time; after 9 months of treatment, the ICS + LABA dosage was reduced to once a day, one inhalation per time; after 18 months of treatment, inhalations were performed every 2 days, one inhalation per time. The initial omalizumab dosage was 150 mg/month. Starting from 18 months, the dosage was changed to 150 mg/2 months up to 24 months of follow-up. The patient reported no side effects.

SCIT was initiated 6 months after the beginning of ICS/LABA/omalizumab treatment. Mite allergen-specific immunotherapy was carried out by subcutaneous injections of the high-dose house dust mite allergoid (Alutard SQ, Denmark), which is provided in the form of four injectable vials with the following concentrations: 100 SQ-U/mL for vial 1; 1,000 SQ-U/mL for vial 2; 10,000 SQ-U/mL for vial 3; and 100,000 SQ-U/mL for vial 4. The dose escalation rules were as follows:

Vial 1: 0.2 mL, 0.4 mL, and 0.8 mL (1–3 weeks).

Vial 2: 0.2 mL, 0.4 mL, and 0.8 mL (4–6 weeks).

Vial 3: 0.2 mL, 0.4 mL, and 0.8 mL (7–9 weeks).

Vial 4: 0.1 mL, 0.2 mL, 0.4 mL, 0.6 mL, 0.8 mL, and 1.0 mL (10–15 weeks).

In the first 15 weeks, the injections were administered once a week. After 15 weeks, injections were administered once a month. Each injection had a dose of 1.0 mL (Figure 1). On the 12-month visit, the patient reported wheezing after the desensitization treatment. The follow-up history revealed that ICS had been discontinued on its own. Self-discontinuation or self-reduction of medication can lead to a state of uncontrolled asthma (Rogers and Reibman, 2012). Therefore, it is plausible that due to the predominantly allergic nature of asthma, a patient who discontinues the medication on their own while being exposed to high concentrations of mite allergens during SCIT can eventually develop an acute asthma attack. The child was instructed to resume regular medication, and the symptoms resolved.

The recorded patient outcomes included subjective improvement, rhinitis symptoms, asthma symptoms, quality of life, and food allergies.

Asthma severity was assessed using the Childhood Asthma Control Test (CACT), a childhood asthma control tool with seven questions. The first four questions have a score range of 0–3, and the last three questions have a score range of 0–5, for a total score of 27. The scores were as follows: score ≤19, uncontrolled asthma; 20–22, partially controlled; and ≥23, well-controlled (Liu et al., 2007).

Additionally, asthma symptoms and allergic rhinitis symptoms were assessed using the visual analog scale (VAS) score, a subjective visual analog scale that rates rhinitis or asthma symptoms, with a score of 0 representing no symptoms and 10 representing the most severe symptoms (Bousquet et al., 2007). Symptom scores were assessed based on the severity of the main symptoms of asthma/rhinitis (asthma assesses cough, wheezing, shortness of breath, and chest tightness, and rhinitis assesses nasal congestion, itchy nose, runny nose, and sneezing). The classifications were as follows: none, no symptoms; mild, symptoms are mild and easily tolerated; moderate, symptoms are noticeable and annoying but tolerable; and severe, symptoms are intolerable and interfere with daily life or sleep (Zhonghua, 2022).

The quality of life was assessed using the Pediatric Asthma Quality of Life Questionnaire (PAQLQ), which consists of 23 questions, each rated on a scale of 1–7 (Sztafińska et al., 2017), with higher scores indicative of a better quality of life.

ADHD symptoms were assessed according to the Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-IV) (Pappas, 2006) and Swanson, Nolan, and Pelham Rating Scale (SNAP-IV-18), an 18-question reporting inventory designed to measure attention deficit/hyperactivity disorder (ADHD) (Swanson et al., 2001).

The ambient Air Quality Composite Index (AQCI) was used to assess the comprehensive condition of urban ambient air quality. The AQCI considers the pollution degree of six pollutants, namely, SO₂, NO₂, PM10, PM2.5, CO, and O₃. A higher value of the AQCI indicates a heavier pollution degree.

As shown in Table 1, after 6–9 months of omalizumab treatment, AR, asthma symptoms, and food allergy were basically controlled. A 12-month follow-up showed that the child developed wheezing after SCIT treatment. Blood work (Table 2) showed a continuous marked improvement with progression of the treatment, with an almost twofold decrease in the white blood count (WBC) levels, and an eightfold decrease in the EOS levels (%) 24 months after the beginning of the ICS/LABA treatment, which corresponds to the 18 months after the beginning of the SCIT treatment. Similarly, pulmonary function tests (Table 3) demonstrated a marked improvement in the lung function of the patient.

As shown in Table 4, after the treatment, ADHD symptoms and the quality of life of the patient markedly improved.

Environmental air quality was continuously monitored throughout the entire course of the treatment (Table 5), and no marked fluctuations in the levels of pollutants were detected.