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In Senegal, tuberculosis is endemic, and tuberculosis patients are supposed to be properly cared for in all healthcare facilities, but a significant proportion of them reach the top of the healthcare pyramid to receive adequate care, and there is little information available on the therapeutic pathway of tuberculosis patients prior to their admission at the reference facilities. Objective: To describe the therapeutic pathway of patients hospitalized in the national reference department with a diagnosis of tuberculosis and to identify the missed opportunities (for diagnosis and treatment). Methods: Retrospective study on the records of hospitalized tuberculosis patients from 2020 to 2022. The identification of factors associated with multifocal TB was carried out using a logistic regression model. The cumulative incidence of death was assessed using Kaplan-Meier curves, and the identification of prognostic factors was done using a Cox regression models. Results: We included 363 patients with a median (IQR) age of 39 (30-50) years, including 61.6% of men and 51.6% of people living with HIV. Before their admission at the national reference department, 88.6% had been seen at another healthcare facility. Missed opportunities for tuberculosis diagnosis were identified in 62.4% of them; otherwise, missed opportunities for tuberculosis treatment occurred in 28.7% of cases and missed opportunities for HIV infection screening in 43.4% of cases. Tuberculosis was unifocal in 30.4% of cases, bifocal in 35.8%, and multifocal in 33.8%. Multifocal tuberculosis was associated with the existence of a missed opportunity for tuberculosis treatment (OR = 3.2. The fatality rate was 7/100 person-months: 7.3/100 personmonths among people living with HIV compared to 6.8/100 person-months among others. After adjustment, age > 55 years (HR = 1.6; p – 0.038) and diabetes as a comorbidity (HR = 2; p – 0.024) were prognostic factors for tuberculosis; the risk of death was associated with a CD4+ T-cell count < 50/mm3 in people living with HIV, being 10 times higher in those with a CD4+ T-cell count < 50/mm3 . Conclusion: Tuberculosis was common, particularly among people living with HIV, whose therapeutic pathway with missed opportunities for diagnosis and treatment could contribute to their advanced immunosuppression upon arrival at the national reference department and, consequently, help explain the high lethality of tuberculosis.