Patient X is an 80-year-old Caucasian male with an extensive past medical history including late-stage Alzheimer’s dementia, peripheral vascular disease, hypertension, hyperlipidemia, diabetes mellitus type 2, hypothyroidism, atherosclerotic coronary artery disease, heart failure and chronic kidney disease. Of note, Patient X’s wife is a resident of the same nursing home and shares a room with him. His wife tested positive in the initial swabbing of the facility following sentinel case detection, along with 21 other residents and 13 staff members.

At the onset of the outbreak, the facility implemented strict facility-wide infection control measures, including full personal protective equipment (PPE) consisting of N95 mask, contact gown, gloves, and emphasized hand hygiene. The 1st floor east-wing of the nursing home was transitioned into the COVID-19 isolation area, and all negative patients were relocated to other units. However, Patient X was allowed to continue to reside with his wife in the same room both for the sake of compassionate care and under the assumption that he was likely an asymptomatic carrier whose first PCR swab returned a false negative. Due to the patient’s dementia and cognitive communication deficits, he was unable to follow any of the suggested face-masking or hand hygiene guidelines. For instance, several staff members observed him helping feed his wife with his fingers without any hand hygiene before or after. These contacts occurred before, during, and after his wife’s symptomatic period, thus suggesting an exceedingly high likelihood of exposure to SARS-CoV-2.

After detection of the initial case of SARS-CoV-2 infection, the LTCF implemented weekly PCR testing to contain the outbreak. Patient X had negative PCR nasopharyngeal tests over a 3-month period. It was postulated that X might have had the infection prior to sentinel case detection on 03/22/2020 and was therefore demonstrating PCR negativity secondary to preexisting humoral immunity. Serology testing was performed, and patient X returned negative for both IgG and IgM antibodies.

Patient Y is a 71-year-old Caucasian female with a past medical history including Parkinson’s disease, major depressive disorder, osteoporosis, type 2 diabetes, peripheral vascular disease, hypertension, hyperlipidemia, history of DVT, and lumbosacral spondylosis. Like Patient X, Patient Y was a long-term resident of the LTCF who resided in the building throughout the entirety of the COVID-19 outbreak. Notably, the patient’s first PCR test on 03/23/20 with the initial sweep of the nursing home was unable to be processed. Because she could not be ruled out for SARS-CoV-2, she was kept in the isolation unit to prevent any further transmission to confirmed negative residents. As the isolation unit began to reach capacity, a positive patient was subsequently roomed with Patient Y on 03/26/20. This roommate was symptomatic starting on 03/23/20 with a fever of 102.3F documented that evening. She progressed to become lethargic with rapid, labored breathing, hypoxemia, and cough. Ultimately this resident was transferred out of the facility on 04/06/2020 and expired on 04/07/2020. Prior to this patient’s discharge from the facility and while roomed with Patient Y, PPE could not be maintained due to the patient’s declining clinical status. However, despite Patient Y’s exposure to a symptomatic roommate, she subsequently tested negative via PCR over a 3-month period, with negative IgG and IgM testing as well.