Chronic cavitary lung disease is an uncommon manifestation of pulmonary infection, and is a pattern which worldwide is most commonly caused by reactivation tuberculosis. Other organisms, however, can cause similar radiologic patterns. Endemic fungi have long been recognized as potential causes of this pattern in North and South America, but the frequency with which these diseases present with chronic cavities in North America is relatively small. Nontuberculous mycobacteria and chronic aspergillus infections are recognized with increasing frequency as causes of this pattern. Melioidosis, a bacterial infection that can also cause chronic lung cavities, was previously understood to be relevant primarily in Southeast Asia, but is now understood to have a wider geographic range. While cultures, serologies, and other laboratory methods are key to identifying the infectious causes of chronic lung cavities, radiologic evaluation can contribute to the diagnosis. Differentiating the radiologic patterns of these diseases from reactivation tuberculosis depends on subtle differences in imaging findings and, in some cases, appreciation of underlying lung disease.