CLOUDY WHITE AREA ON CHEST XRAY

[Lyons]

Forties woman with increasing shortness of breath.  Stopped smoking in 1999.  Active until now.

8 weeks ago:  Sudden onset of pain in back left lung.  Hospitalized for suspected pulmonary embolism, negative.

CT angiogram w/ contrast dye:  'Similar to prior xrays, there is biapical fine and coarse reticular change predominantly in the posterior apices with associated cephalad retraction of the hila and apical volume loss.  Likely longstanding chronic fibrotic process that is secondary to old granulomatous disease.  Increased pleural opacity at medial left upper lobe, left apex and lateral left upper lobe.  Increased opacity at left base.  Suggest this opacity is fluid or near fluid in attenuation.  Associated traction bronciectasis that is most noted in the posterior left apex. Mild hyperinflation.'
Diagnosed viral pleurisy.

4 weeks later:  Increasing shortness of breath.  CXR showed new cloudy white area covering bottom half of left front lung area.  

4 days later:  Outbreak of shingles. Left side at 7th and 8th dermatones.

2 weeks later:  2nd CXR showed little change.  1st DR said diaphragm was elevated, but does not think cloudy white area is liquid fluid.  Advised to wait.  

1 week later:  2nd DR said white area is pleural effusion and recommended thoracentesis.  Possible thorocoscopy if not improved.

We don't know if we should wait or have procedure(s).
Both pulmonologists are well-respected.
Also, could one get zoster in the lungs or pleural lining, causing white areas, SOB or elevated diaphragm?

Thank you kindly,
Lyons

[National Jewish]

Yes, it is possible for Herpes Zoster, also known as Shingles, to cause pneumonia.  The pneumonia would appear as white areas on a chest x-ray. Shingles can cause paralysis of one side of the diaphragm, which would appear on a chest x-ray as an elevated diaphragm on that side.
If it is a paralyzed diaphragm, neither thoracoscopy nor thoracentesis is needed, since this paralysis generally resolves over time.  However if it is an effusion, a thoracoscopy will provide more information than a thoracentesis.  A radiologist can be helpful in determining if it is a paralyzed diaphragm or an effusion.