Spondyloarthritis（SpA）is consist of several diseases with asymmetric peripheral arthritis, adhesions, inflammatory back pain, and extra-articular symptoms as common clinical symptoms. Historically, the expression and inclusion of the disease has changed with changes in the disease concept, previously referred to as seronegative spondyloarthropathies（SNSA）. Assessment of Spondyloarthritis International Spondyloarthritis international society; ASAS）in 2009-2011, the classification criteria for axial spondyloarthritis（ax SpA）and peripheral spondyloarthritis（peripehral SpA; pSpA）were proposed and have been implemented to date. The clinical manifestations of spondyloarthritis are diverse and heterogenous, and there are few useful biomarkers for diagnosis. Therapeutics have been remarkably improved in recent years, and it is important to accurately diagnose spondyloarthritis.

  Imaging is indispensable to make a diagnosis of spondyloarthritis（SpA）. It is important to check the condition simple X-rays image or MRI before evaluatioin. The evaluation of the sacroiliac joint is important for the diagnosis of axial SpA. We should focus on the articular surface which is located in a lower half of iliac bone. In the spine, syndesmophytes, which is unique for axial SpA, start straight up from the fibrous ring of vertebral disk. On the other hand, syndesmophytes of psoriatic arthritis（PsA）look chunky and start from the vertebral body but not discs. We should also distinguish axial SpA from PAO, DISH, or OCI.

  In MRI, we confirm existence of inflammation and a structural change. Inflammation, so called bone marrow edema（BME）, is presented by low intensity area in T1WI and high in STIR or T2fs images. BME just suggests existence of inflammation, and we sometime find it even in injury or infection. Structural change is relatively easy to find in T1WI.

  In peripheral arthritis seen in PsA, we could find new bone formation around the enthesis. Once secondary synovitis is occurred, we see not only bone resorption in the joint, but also bone formation out of the joint.

Axial spondyloarthritis（axSpA）includes ankylosing spondylitis（AS）and non-radiographic spondyloarthritis（nr-axSpA）. nr-axSpA is a disease concept proposed as a pre-radiographic stage of AS, but not all of them progress to AS. The main symptom of axSpA is chronic, young-onset inflammatory back pain. Peripheral symptoms are associated with peripheral arthritis and enthesitis in 30% to 50% of patients. Extra-articular lesions include uveitis, inflammatory bowel disease, and psoriasis etc. Other information such as CRP/ESR, HLA-B27, family history of SpA, and good response to NSAIDs are also helpful for diagnosis. First line of pharmacological therapy is NSAID, and b/tsDMARD are positioned as second line. But if the response is not appropriate, diagnosis, comorbidity and adherence should be re-evaluated.

Psoriatic arthritis（PsA）is closely associated with a reduction in quality of life（QOL）, akin to rheumatoid arthritis, and delays in diagnosis can result in progressive joint destruction and long-term physical disability. Early diagnosis necessitates a thorough understanding of the key clinical manifestations of PsA. This includes not only the assessment of dermatological and nail lesions, present in up to 90% of PsA patients, but also a comprehensive evaluation of peripheral and axial joint involvement through detailed medical history, physical examination, and advanced imaging techniques.

In terms of treatment, a treat-to-target（T2T）approach, informed by recent advancements in pharmacotherapy, is essential. Treatment strategies should be personalized, considering individual disease activity（including axial involvement）and patient-specific factors, such as the presence of comorbidities. It is critical that treatment decisions are made collaboratively between the clinician and the patient, with a careful selection of therapeutic agents, including molecular targeted therapies, based on their pharmacological profiles. This discussion will be grounded in the EULAR treatment recommendations updated in 2023.

  Reactive arthritis（ReA）is a sterile arthritis occurring in a genetically predisposed individual, secondary to an extra-articular infection, usually of the gastrointestinal or genitourinary tract. Sterile arthritis associated with tonsillitis by streptococcal infection, extraarticular tuberculosis and intravesical instillation of Bacillus Calmette-Guerin（iBCG）therapy used for bladder cancer also could be included in ReA considering the pathogenic mechanism. In 1999, ReA international workshop suggested that ReA was related to HLA-B27 and associated with spondyloarthritis symptoms, and was a sterile arthritis occurring secondary to an extra-articular infection, usually limited of the gastrointestinal or genitourinary or a part of respiratory tract. Moreover, it was also suggested that except septic arthritis, sterile arthritis occurring after other infections should be called as infection-related arthritis. However, we often conventionally use “ReA” in infection-related arthritis patients from the point of view of pathogenic mechanism.

  In this section, the epidemiology, pathophysiology, diagnosis and treatment of ReA are reviewed.

Here we report a case of elderly rheumatoid arthritis（RA）complicated by an aspergillus infection treated with an abatacept（ABT）infusion. A 74-year-old woman with RA who had been treated with methotrexate（MTX）for 12 years was referred to our hospital with left ankle joint pain. Her RA was moderately active, but swelling and tenderness were observed in the left talocrural articulation, an indication for biologic disease-modifying antirheumatic drugs（bDMARDs）. In the screening test for infection, β-d-glucan was positive at 38.3pg/mL and aspergillus antigen positive at 0.5, but computed tomography showed no consolidation or ground glass opacity in the lung field, but fluid accumulation was present in the left maxillary sinus. She had a history of sinusitis for which antifungal agents were administered before the bDMARDs. She continued to receive MTX 8mg/week, and an ABT 750mg infusion was introduced. The RA activity decreased 3 months later. The fluid accumulation in the left maxillary sinus also disappeared with continuation of the antifungal medication. In RA complicated by infection, treatment should be intensified based on the risk–benefit ratio; however, in the elderly case, further safety considerations are also necessary. In this case, the RA activity promptly decreased after introduction of the ABT, and the patientʼs clinical course showed no exacerbation of the left maxillary sinusitis, suggesting that ABT can be safely used in combination with antifungal agents.

Objective: To clarify the relationship between cognitive impairment and the physical function of elderly patients with rheumatoid arthritis（RA）.

Subjects and Methods: Fifty-two RA patients of ≥ 65 years of age with pre-frailty or frailty were hospitalized for 3 nights and 4 days, and individual exercise and nutritional guidance were provided in conjunction with assessments of their physical and cognitive functions. Grip strength, gait speed, and skeletal muscle index（SMI）were re-examined at 6 and 12 months after discharge. Patients with a mini mental state examination（MMSE）score of ≤ 27 points were classified into the mild cognitive impairment（MCI）group（n=27）and compared with the non-MCI group（n=25）. Changes over time in both groups were compared using a two-way analysis of variance.

Results: The MCI group had weaker grip strength, slower gait speed, shorter stride length, and a longer timed up-and-go test（TUG）than the non-MCI group. Regarding changes over time, only walking speed showed a significant improvement while other items remained unchanged.

Conclusion: The decline in the physical function tended to be advanced when cognitive impairment was observed in elderly patients with RA. Early intervention is important for preventing the decline of the cognitive and physical functions of patients with cognitive impairment.