Asphyxial Mechanisms in Sand Burial, Findings and Diagnostic Challenges—A Case Report and a Literature Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Please see the detailed comments below. The manuscript may be considered for publication after minor revision.

Comments for author File: Comments.pdf

Author Response

"Thank you for the opportunity to review this manuscript.

The manuscript deals with a rare and relevant topic in the medico-legal field, integrating a

case report with a review of the literature relating to asphyxial mechanisms in sand burial.

The work is overall well structured, clear in its approach and supported by a good autopsy

and histological description. Of particular interest is the attempt to distinguish the

predominantly compressive mechanisms from those related to the obstruction/inspiration

of particulate material, which represents the main element of originality of the work. The

case appears coherent from an anatomical-pathological point of view and the discussion is

generally balanced; iconographic documentation is also useful for interpretative purposes."

We are grateful to the reviewer for their appreciation of our paper and for the insightful suggestions. We have accordingly revised the manuscript in line with these suggestions (the changes are reported in red).

However, some methodological and interpretative aspects need clarification and revision in

order to improve the overall scientific soundness of the manuscript.

Firstly, the literature review part requires a better methodological definition. The authors

correctly state that the review does not fully adhere to the PRISMA criteria; despite this, the

reference to a "systematic literature review" in the title and abstract appears not entirely

consistent with the methodology actually adopted. It s preferable to use a more

conservative and methodologically appropriate definition, so as to align the terminology

with the actual structure of the study.

We have revised the title and performed a risk-of-bias assessment of the previously retrieved articles, including the addition of the study by Halasi et al., retrieved on the suggestion of a reviewer.

The bibliographic search strategy also needs more in-depth study. The strings used are

rather restrictive and mainly based on the terms "bury", "buried" and "burial", with the risk

of not intercepting relevant cases described with different terminologies. The inclusion of

additional terms such as "sand aspiration", "compressive asphyxia", "traumatic asphyxia",

"soil aspiration", "tunnel collapse" or "buried alive" should be considered. In addition, it

would be appropriate to specify the date of the last bibliographic search and to explain the

rationale of the temporal cutoff adopted.

We considered that avoiding specification of the particulate matter type could increase the sensitivity of the search. Indeed, the study by Halasi et al. also reports in the abstract the keywords used for the search strategy. We nonetheless specified that the search was conducted up to November 2025. From the examination of the Halasi et al. article, although an online publication in 2025 is indicated, it is listed as a 2026 article; this discrepancy may explain why it was not retrieved. Alternatively, the ‘humans’ filter may have further contributed to its exclusion.

We also tried conducting a free search on Google Scholar by including additional terms such as those suggested by the reviewer, but no further relevant articles emerged that could be included in our paper.

 

The Methods section also presents some stylistic and grammatical criticalities. There are

some redundant repetitions in the description of the study selection process and data

extraction. There is also an inconsistency in the section numbering: after "3. Materials and

Methods", the manuscript reports "3. Results", an element that requires editorial correction.

We fixed the numeration of the chapters and revised the methods section.

 

As regards the interpretative conclusions, the wording appears to be excessively assertive

compared to the available data. Although the hypothesis of a predominantly compressive

mechanism is plausible and well argued on the basis of reconstructive dynamics and

autopsy findings, the presence of sand in the upper airways requires greater interpretative

caution and suggests keeping open the hypothesis of a mixed mechanism, even if with a

compressive prevalence. A less categorical formulation would make the manuscript more

balanced from a medico-legal point of view.

We revised the discussion and the conclusions, trying to be less assertive on the mechanisms of asphyxia. We highlighted also several limits of the review based on the small number of studies retrieved and on their heterogeneity.

The discussion on the haemorrhagic findings of the laterocervical lymph nodes is also of

interest. However, considering the extremely limited number of cases available and the

absence of data demonstrating its specificity or real diagnostic value, this finding should be

presented with greater caution as an exploratory and non-specific observation, avoiding the

risk of attributing to it a higher interpretative weight than that supported by the currently

available literature.

We revised the paper according to the suggestions.

Descriptively, the manuscript would benefit from the inclusion, if available, of additional

quantitative autopsy data, such as the weight of the lungs, heart and brain, as well as more

details on the distribution of particulate matter in the distal airways. It would also be useful

to specify whether toxicological tests were performed in the index case and to briefly report

the results.

We revised the paper according to the suggestions, reporting the weight of the lungs, heart and brain and the results of the toxicology (negative).

The section dedicated to the limitations of the study requires a substantial review in

particular it should highlight more clearly the real methodological limitations of the review,

including the small number of available cases, the heterogeneity of the autopsy and

histological descriptions, and the impossibility of drawing generalizable conclusions;

summarizing the findings that emerged in the included cases is not enough.

We revised this section according to the suggestions.

There are also some stylistic and linguistic inconsistencies, in particular in the alternation

between British and American terminology ("haemorrhage/hemorrhage",

"oedema/edema"), which require editorial uniformity.

We revised the entire paper according to the suggestions to uniform the terminology.

Overall, the work addresses a rare but relevant topic in forensic practice and presents

elements of scientific interest.

We are sincerely grateful for the valuable suggestions which have significantly contributed to improving our work. We hope that our efforts and the revisions made will be appreciated.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

the manuscript entitled “Asphyxial mechanisms in sand burial: findings and diagnostic challenges – A case report and systematic literature review” is well written. The authors demonstrate awareness of the limitations of their manuscript, as outlined in Section 5, which is commendable. It is also worth noting positively that the manuscript cites up-to-date publications. Minor revisions are suggested: Lines 345–346: repetition of “during”. Lines 141–142: the sentence could be phrased more elegantly. Although the paper does not address a novel topic, in my opinion it merits publication for the reasons outlined above.

Yours sincerely,
Reviewer

Author Response

We are sincerely grateful to the reviewer for their appreciation of our work and for the insightful suggestions provided. We have revised the manuscript accordingly, incorporating these comments as well as those of the other reviewers; all modifications have been highlighted in red throughout the revised version of the manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

This is a clinically interesting case with reasonable forensic reasoning. However, the manuscript has substantial methodological weaknesses for a paper labeled "systematic literature review," several misleading or weak citations, an underdeveloped discussion of differential mechanisms and CPR-related confounders, and editorial inconsistencies. Below are some comments that should be addressed:

• methods section acknowledge that "the review did not strictly adhere to all the methodological requirements of the PRISMA guidelines" (no protocol registration, no formal risk-of-bias assessment). With only two databases searched (PubMed and Scopus), no protocol, no risk-of-bias evaluation, no formal data synthesis, and a qualitative narrative only, this is more accurately a scoping review or narrative review with systematic search elements. The title should be amended to "scoping review" or "narrative review." Calling it "systematic" is a little misleading.
• additionally, the search strategy described is unusually narrow: keywords listed are only "bury", "buried", "burial", "fatal", "forensic", "autopsy". Critical terms such as "sand", "soil", "asphyxia", "smothering", "sand aspiration" are absent from the visible string. The reader cannot reproduce this search.  Just as an example, A highly relevant 2025 paper, Halasi et al.  2025 ("Severe illness as a risk factor for live burial"), describes homicidal live burial of a 32-year-old woman in a shed/grave with airway obstruction by soil confirmed by polarized light microscopy. This case meets all stated inclusion criteria but is not cited
• The discussion cites Oehmichen and Schmidt 1989 as one of the supporting references for hemorrhagic laterocervical lymph node findings. The actual conclusion ofthat study is opposite of what the citation context implies: "Neither follicular hemorrhage nor the presence of red blood cells in the sinus is diagnostically significant in forensic pathology." This is one of the strongest negative findings in the cervical lymph node literature, and the manuscript cites it as if to support, rather than to caveat, the lymph node finding. The authors do hedge their interpretation as "non-specific," but pairing this hedge with this particular citation in a positive framing is misleading
• CPR was performed on this victim. The discussion briefly mentiones  that "cardiopulmonary resuscitation and traumatic recovery procedures may account for some postmortem changes, including the hepatic laceration." This treatment is far too thin. CPR-associated lung edema is a well-documented phenomenon with pulmonary edema, alveolar hemorrhage, and reduced airspace as hallmarks, demonstrated in both experimental and human cardiac arrest populations.  pulmonary edema and congestion in this case could be partly or even predominantly attributable to CPR rather than to the asphyxial mechanism itself. The single most cited autopsy finding in the case (and in the review) is therefore the one most vulnerable to a CPR-related explanation. The manuscript should address this directly. 

• regadring the liver injury - the text dismisses this as "CPR-related" and "without vital reaction." HOwever, 350 mL is non-trivial; was hemoperitoneum volume consistent with the lack of vital reaction (i.e., truly post-CPR rather than peri-arrest)?could not direct trauma during the tunnel collapse (impact of falling sand body, or recovery extrication) account for this? This should be further analyzed, as liver lacerations during CPR in the young is quite rare

• in figure 3 - 916 duplicates from 1301 records (70% duplication) is implausibly high between two databases. 
• the discussion repeatedly mentiones the usefulness of hemorrhagic laterocervical lm involvement; however, the literature references in this area are scant (Kiryu); the authors should take into account that lymph nodes are highly vascularized structures, and post CPR venous congestions and prolonged supine recovery could explain the subcapsular hemorrhage. 
• in the legend of figure 2 - Panel B is described as "Perilymph nodal tissue with hemorrhagic infiltration" but panel C and D also reference subcapsular/perinodal hemorrhage; the redundancy is confusing without seeing scale and orientation markers explicitly defined.
• Table 1 -  for tje Zarroug case 1, Battle sign is listed under External Examination and No under Petechiae; Battle sign (mastoid ecchymosis, typically a basilar skull fracture sign) is unexpected in a compressive asphyxia death without trauma
• the authors stated that "a pattern emerges whereby compression-related mechanisms appear more frequently represented in accidental tunnel-collapse cases." With 7 cases total across 5 studies, of which 2 (Zarroug) are explicitly compression and 2 (Kiryu) are mixed compression-with-some-neck-component, this "pattern" is descriptive at best and should be presented with explicit numeric caution

Author Response

We are grateful to the reviewer for their appreciation of our paper and for the insightful suggestions intended to address the methodological gaps and limited depth of the literature review in the initial version. We have accordingly revised the manuscript in line with these suggestions (the changes are reported in red).

“methods section acknowledge that "the review did not strictly adhere to all the methodological requirements of the PRISMA guidelines" (no protocol registration, no formal risk-of-bias assessment). With only two databases searched (PubMed and Scopus), no protocol, no risk-of-bias evaluation, no formal data synthesis, and a qualitative narrative only, this is more accurately a scoping review or narrative review with systematic search elements. The title should be amended to "scoping review" or "narrative review." Calling it "systematic" is a little misleading.”

We have revised the title and performed a risk-of-bias assessment of the previously retrieved articles, including the addition of the study by Halasi et al.

“additionally, the search strategy described is unusually narrow: keywords listed are only "bury", "buried", "burial", "fatal", "forensic", "autopsy". Critical terms such as "sand", "soil", "asphyxia", "smothering", "sand aspiration" are absent from the visible string. The reader cannot reproduce this search.  Just as an example, A highly relevant 2025 paper, Halasi et al.  2025 ("Severe illness as a risk factor for live burial"), describes homicidal live burial of a 32-year-old woman in a shed/grave with airway obstruction by soil confirmed by polarized light microscopy. This case meets all stated inclusion criteria but is not cited.

We considered that avoiding specification of the particulate matter type could increase the sensitivity of the search. Indeed, the study by Halasi et al. also reports in the abstract the keywords used for the search strategy. We nonetheless specified that the search was conducted up to November 2025. From the examination of the Halasi et al. article, although an online publication in 2025 is indicated, it is listed as a 2026 article; this discrepancy may explain why it was not retrieved. Alternatively, the ‘humans’ filter may have further contributed to its exclusion.

We have nevertheless included the study by Halasi et al., which was retrieved via a free Google Scholar search.

The discussion cites Oehmichen and Schmidt 1989 as one of the supporting references for hemorrhagic laterocervical lymph node findings. The actual conclusion ofthat study is opposite of what the citation context implies: "Neither follicular hemorrhage nor the presence of red blood cells in the sinus is diagnostically significant in forensic pathology." This is one of the strongest negative findings in the cervical lymph node literature, and the manuscript cites it as if to support, rather than to caveat, the lymph node finding. The authors do hedge their interpretation as "non-specific," but pairing this hedge with this particular citation in a positive framing is misleading.

We have aimed to clarify that lymph node hemorrhage is not a specific indicator of asphyxia. We have consistently reiterated this aspect, while also noting its potential relevance in sand burial deaths, particularly in view of future research.

CPR was performed on this victim. The discussion briefly mentiones  that "cardiopulmonary resuscitation and traumatic recovery procedures may account for some postmortem changes, including the hepatic laceration." This treatment is far too thin. CPR-associated lung edema is a well-documented phenomenon with pulmonary edema, alveolar hemorrhage, and reduced airspace as hallmarks, demonstrated in both experimental and human cardiac arrest populations.  pulmonary edema and congestion in this case could be partly or even predominantly attributable to CPR rather than to the asphyxial mechanism itself. The single most cited autopsy finding in the case (and in the review) is therefore the one most vulnerable to a CPR-related explanation. The manuscript should address this directly. regadring the liver injury - the text dismisses this as "CPR-related" and "without vital reaction." HOwever, 350 mL is non-trivial; was hemoperitoneum volume consistent with the lack of vital reaction (i.e., truly post-CPR rather than peri-arrest)?could not direct trauma during the tunnel collapse (impact of falling sand body, or recovery extrication) account for this? This should be further analyzed, as liver lacerations during CPR in the young is quite rare

Case-specific information indicates that more than 30 minutes had elapsed between the last time the victim was seen alive and the discovery of the body. Moreover, no signs of forceful compression were observed, such as rib fractures or hemorrhagic infiltration of the intercostal or cervical muscles. We have specified that the cardiac alterations may be related to CPR, although they were of mild degree (fragmentation of the subpericardial myofibers). We have nevertheless avoided overly categorical statements regarding the non-vital nature of the hepatic laceration and have left open the possibility that the blood collection may have been facilitated by CPR, either through a laceration or, at least, through compression of vascular structures.

in figure 3 - 916 duplicates from 1301 records (70% duplication) is implausibly high between two databases. 

We re-conducted the screening using both Zotero and Rayyan, and obtained results consistent with those previously reported.

the discussion repeatedly mentiones the usefulness of hemorrhagic laterocervical lm involvement; however, the literature references in this area are scant (Kiryu); the authors should take into account that lymph nodes are highly vascularized structures, and post CPR venous congestions and prolonged supine recovery could explain the subcapsular hemorrhage. 

We have sought to improve this point by downplaying the importance attributed to lymph node hemorrhage, specifying that it is a non-specific finding in asphyxial deaths and that it should be interpreted in the context of additional circumstantial, autopsy, and ancillary findings.

in the legend of figure 2 - Panel B is described as "Perilymph nodal tissue with hemorrhagic infiltration" but panel C and D also reference subcapsular/perinodal hemorrhage; the redundancy is confusing without seeing scale and orientation markers explicitly defined.

Thank you. We fixed it.

Table 1 -  for tje Zarroug case 1, Battle sign is listed under External Examination and No under Petechiae; Battle sign (mastoid ecchymosis, typically a basilar skull fracture sign) is unexpected in a compressive asphyxia death without trauma.

We thank the reviewer for the comment. Indeed, Battle’s sign is an external finding, similarly to raccoon eyes in cases of skull base trauma. We have therefore included it in the external examination; however, this does not imply that we consider it an asphyxial sign, but rather that it is a feature reported by the authors in their case report, as is hemotympanum.

“The authors stated that "a pattern emerges whereby compression-related mechanisms appear more frequently represented in accidental tunnel-collapse cases." With 7 cases total across 5 studies, of which 2 (Zarroug) are explicitly compression and 2 (Kiryu) are mixed compression-with-some-neck-component, this "pattern" is descriptive at best and should be presented with explicit numeric caution”

We have revised the Results and the Discussion, highlighting that the mechanisms may be compressive, inhalational/obstructive, or, in some cases, mixed. Indeed, this requires a multi-level investigative approach to better understand the cause of death. Rather than providing quantitative estimates, also in light of the small sample size and heterogeneity, we have emphasized that the analysis should be qualitative and multi-layered in order to derive a more plausible cause of death.

 

 

Reviewer 4 Report

Comments and Suggestions for Authors

I read the article with great interest, particularly because it discusses a rare form of mechanical asphyxia. I think the case has been described in a very detailed and clear way, especially with regards to the autopsy and histological findings. I also believe that reviewing the literature on similar cases is important in order to compare the results of autopsy and histological examinations in order to evaluate the possible presence of analogies. However, I would like to suggest that the authors further investigate the differential diagnosis between accidental burial and homicidal burial, that is, what the differences might be, for example, at the scene of the event, also considering that in one of the seven cases analyzed, among those previously published by other authors, there was a case of homicide.

Author Response

We are sincerely grateful to the reviewer for their appreciation of our work and for the insightful suggestions provided. We have revised the manuscript accordingly, incorporating these comments as well as those of the other reviewers; all modifications have been highlighted in red throughout the revised version of the manuscript.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

in figure 3 - 916 duplicates from 1301 records (70% duplication) is implausibly high between two databases - this would mean that you have more articles that total records?

The rest of my enquiries were answered.

 

 

 

Author Response

Dear Reviewer,

We sincerely thank you for your careful and timely review of our work. Due to an issue with the review software, we had mistakenly reported an incorrect number of duplicates. We have now corrected both the flow chart and the corresponding figures in the text.

We are also grateful for your valuable suggestions, which allowed us to identify and correct a clear methodological error.